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NHS has missed opportunities to learn from patient deaths, says CQC

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The NHS is failing to learn from patient deaths with grieving families often excluded or left in the dark during investigations, a national review by the Care Quality Commission has found.

The highly critical report from the regulator, published today, raises serious concerns about the quality of investigations by trusts into deaths.

“Too often, opportunities are being missed to learn from deaths”

Mike Richards

It also uncovers widespread inconsistency in practice including when it comes to whether the circumstances surrounding a patient death are looked into or not.

The nationwide CQC review – requested by health secretary Jeremy Hunt – was sparked by a report identifying failings in the way deaths of patients with learning disabilities and mental health problems at Southern Health NHS Foundation Trust were handled and investigated.

This in turn followed a probe into the death of Connor Sparrowhawk, whose family had to push for a full investigation after the 18-year-old died while in the care of the trust.

The CQC review is based on evidence gathered during visits to a sample of 12 trusts, a national survey of NHS providers, interviews with more than 100 families and information from charities and health professionals.

“We found that too often, opportunities are being missed to learn from deaths so that action can be taken to stop the same mistakes happening again,” said CQC chief inspector of hospitals Professor Sir Mike Richards.

Sir Mike Richards

Sir Mike Richards

Sir Mike Richards

“Families and carers are not always properly involved in the investigations process or treated with the respect they deserve,” he said. “We found this was particularly the case for families and carers of people with a mental health problem or learning disability which meant that these deaths were not always identified, well investigated or learnt from.

“While elements of good practice exist, there is not a single NHS trust that is getting it completely right currently,” he added.

The report includes examples of highly insensitive nursing care described by bereaved family members.

“I was put in a room. I shall never forget what the nurse in the room told me. She said: ‘You have got to accept that his time has come’, bearing in mind my son was just 34 years old,” one grieving relative told the CQC.

“We must now ensure we rapidly put in place system-wide changes”

Sue Bailey

In another example cited in the report, a nurse interviewed by the CQC describes the shambolic investigation into the death of patient who may have died after a fall.

“We’re still not sure whether he did fall or not,” the nurse said. “There was no blame involved but the way it was handled was dreadful. It was quite embarrassing to be a nurse at that period of time.”

While the review found healthcare staff knew to report safety incidents, there was no agreed process to identify whether a death may require further investigation.

The CQC said this lack of clarity meant there were some deaths that not been investigated which should have been.

The review found acute and community trusts did not always record whether a patient had a mental health illness or learning disability.

Academy of Medical Sciences

NHS must learn from patient deaths, says regulator

Sue Bailey

Meanwhile, not all staff involved in carrying out investigations and reviews had specialised training and support or protected time to carry out investigations.

In the light of its findings, the CQC is calling for a new national framework clearly setting out the action trusts must take when someone in their care dies.

The regulator also said it would place greater emphasis on the way deaths were investigated by trusts as part of inspections.

Professor Dame Sue Bailey, chair of the Academy of Medical Royal Colleges, said it was vital lessons were learned from the report.

“We must now ensure we rapidly put in place system-wide changes so that NHS trusts always treat families as equal partners in a consistent manner with humanity, honesty and common decency when deaths occur,” she said.

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