Learning, candour and accountability – How NHS trusts review and investigate the deaths of patients in England

The Care Quality Commission (CQC) has published a report focusing on the actions taken by NHS trusts when a patient dies in hospital which considers how they investigate and learn from the deaths of patients under their care. The report makes several recommendations for change, which have been accepted by the Government and will come into force on 31 March 2017.

Despite the NHS’s Duty of Candour, the report found that many families still experience a lack of transparency and feel their involvement in the investigative process when a relative dies in hospital is ‘tokenistic’. As a consequence opportunities to learn from preventable deaths are often missed.

CQC findings

The CQC’s report is the culmination of a one-year inquiry into a number of high-profile cases in which NHS trusts were found guilty of neglect leading to preventable deaths, for example those of Connor Sparrowhawk and Richard Handley. Throughout the report there is an emphasis on the treatment of patients with learning and mental health issues because of their inherent vulnerability.

The CQC has identified a number of issues that have given rise to concern. For example:

• Families and carers often have a poor experience of mortality investigations, questioning the independence of the subsequent reports.
• The NHS does not prioritise learning from deaths and misses opportunities to improve practice.
• There is no single framework setting out how NHS trusts should identify, analyse and learn from deaths of patients in their care.

Practical consequences of the report

The CQC makes a number of recommendations for change. From 31 March 2017, the boards of all NHS trusts and foundation trusts will be required to implement significant changes to practice. The following is not an exhaustive list, but NHS organisations will have to:

• Collect a range of specified information on deaths that were potentially avoidable as well as serious incidents and consider what lessons need to be learned, on a regular basis. This information will be published quarterly.
• Alongside that, publish evidence of learning to show that action is being taken as a consequence of that information.
• The information will also need to be provided to NHS Improvement so the position can be reviewed at a national level.
• Identify a board-level leader as patient safety director to take responsibility for this. The incumbent medical director is likely to be the most appropriate person. A non-executive director will need to be appointed to oversee the process.
• More thorough and genuine involvement of families and carers when deaths result from problems in care.
• Health Education England is to review training for all doctors and nurses around this, to include training on maintaining their own mental health and resilience in extremely challenging situations.
• Review and learn from all deaths of people with learning disabilities in all settings.

Guidelines are to be published by the end of March 2017.

The CQC’s Dr George Julian was clear in stating that the NHS needs to ‘stop talking about learning lessons, to move beyond writing action plans and to actually make change happen.’

Comment

It is important to remember that not all deaths are caused by sub-standard medical care or a lack of appropriate support during life. However, the CQC has highlighted that there is much progress to be made in collecting information about unexpected deaths, analysis of the circumstances surrounding those deaths that were preventable and learning from the results.

An internal investigation provides an effective method for organisational learning and consequential improvements in patient care. The issue of improving patient safety can sometime be onerous, but failing to learn lessons from mistakes is inexcusable.

It is anticipated that there will be an increase in the number of reported avoidable deaths as the culture of lesson learning continues to grow. A number of organisations are now in the process of changing practice, which will help encourage improvements in service delivery sooner rather than later.

It is vital that all of your staff are trained on what is expected from them when patient deaths or other incidents are investigated. We have a range of training options available for staff on how to manage this effectively, whether or not the duty of candour process is engaged.

For more information please contact one of the authors below.