The Care Quality Commission's (CQC) 76 page report "Learning, candour and accountability: a review of the way NHS trusts review and investigate the deaths of patients in England" has revealed:
- Bereaved families are being left without help following the death of a loved one
- Bereaved families are not being included or listened to in official investigations into patient deaths
- Huge concerns over the nature and quality of investigations being conducted following patient deaths
- The NHS is missing opportunities to learn from patient deaths
- Hospitals immediately on the defensive about failures in care
The report carried out at Jeremy Hunt's request is highly critical of how the NHS investigates deaths in England rightly states that:
"two of the behaviours that underpin the vision and purpose of the NHS in England, openness and learning in order to improve, are never needed more than when a patient dies whose care may have been delivered differently and whose death might have been prevented."
It is therefore with much disappointment but ultimately little surprise that, on reading the report, it becomes clear that the NHS is failing miserably in this regard. Take for example the case of Southern Health NHS Foundation Trust. Over a four year period from April 2011, fewer than 1% of all deaths in their learning disability services and 0.3% of deaths in the mental health services for older people were investigated as a serious incident. This is unacceptable and suggests that healthcare providers are failing in their Duty of Candour, which requires that all NHS Trusts are open and transparent with people whose use their services when there are notable safety incidents, obviously including deaths.
Unfortunately the problem is not confined to isolated trusts. In 2015 495,309 deaths were registered in England. Of those, 207,633 died as inpatients or in A&E departments in hospitals. In cases involving those 207,633 deaths, there were a total of 23 level 3, i.e. independent, investigations into the care that was provided, representing a figure of approximately 0.001%. The figure is not much better with regards level 2 investigations, i.e. comprehensive internal investigations, with such investigations only taking place in 0.05% of recorded deaths. Put simply, NHS Trusts are failing to adequately investigate deaths that are occurring in their care.
The report made the following recommendations:
- Learning from deaths needs much greater priority within the NHS to avoid missing opportunities to improve care.
- Bereaved relatives and carers must receive an honest and caring response from health and social care providers and the NHS should support their right to be meaningfully involved.
- Healthcare providers should have a consistent approach to identifying and reporting the deaths of people using their services and share this information with other services involved in a patient's care.
- There needs to be a clear approach to support healthcare professionals' decisions to review and/or investigate a death, informed by timely access to information.
- Reviews and investigations need to be high quality and focus on system analysis rather than individual errors. Staff should have specialist training and protected time to undertake investigations.
- Greater clarity is needed to support agencies working together to investigate deaths and to identify improvements needed across services and commissioning.
- Learning from reviews and investigations needs to be better disseminated across trusts and other health and social care agencies, ensuring that appropriate actions are implemented and reviewed.
- More work is needed to ensure the deaths of people with a mental health or learning disability diagnosis receive the attention they need.
Deborah Coles, director of the charity INQUEST, stated:
“This report is long awaited recognition of the disgraceful, yet prevalent culture of denial and secrecy so brutally experienced by the relatives of those who have died. From the notification of death, through internal investigations, inquests and beyond, relatives have had to fight every step of the way for the truth."
Professor Sir Mike Richards, Chief Inspector of Hospitals at the Care Quality Commission, said:
"Investigations into problems in care prior to a patient's death must improve for the benefit of families and importantly, people receiving care in the future. We have made a number of recommendations for action as a result of this review. This is a system-wide problem, which needs to become a national priority. CQC will support the drive for change by sharing best practice, identifying concerns and taking action to protect patients when necessary."
Mark Bowman, partner at Fieldfisher commented:
"Unfortunately this report comes as no surprise. It has become clear over many years that asking the NHS to act with honesty, integrity and decency is akin to asking Turkey's to vote for Christmas. This report is simply another example of the NHS failing to move forwards and failing in one of its most fundamental duties – supporting those who have lost a loved one under their care. It is clear that only an independent body tasked with investigating the NHS and with the power to enforce sanctions on it will have any chance at all of ensuring the NHS becomes an organisation which we can once again become proud of."