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NHS faces ‘system-wide problem’ as trusts fail to learn from patient deaths


13 December 2016

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Not a single trust could demonstrate good practice when investigating the deaths of patients in their care, according to an inquiry by care regulators.

The Care Quality Commission (CQC) found that NHS trusts lack a single framework to identify what needs to be done to learn from deaths that may be the result of poor care.

This led to many families telling the CQC that they had a poor experience of investigations and were not always treated with kindness, respect and honesty.

Not a single trust could demonstrate good practice when investigating the deaths of patients in their care, according to an inquiry by care regulators.

The Care Quality Commission (CQC) found that NHS trusts lack a single framework to identify what needs to be done to learn from deaths that may be the result of poor care.

This led to many families telling the CQC that they had a poor experience of investigations and were not always treated with kindness, respect and honesty.

The review found that this was particularly the case for families and carers of people with a mental illness or learning disability.

The CQC review looked at how NHS mental health, hospital and acute trusts across the country identify, report, investigate and learn from the deaths of the people in their care.

Jeremy Hunt, secretary of state for health, requested the inquiry following the findings of the NHS England report into the deaths of people with a learning disability or mental illness at Southern Health NHS Foundation Trust.

The CQC is now recommending that the Department of Health and the National Quality Board work with the royal colleges and families to develop a new single framework on learning from deaths.

Professor Sir Mike Richards, chief inspector of hospitals at the CQC, 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.”

He added that the NHS is facing a “system-wide problem” that needs to be prioritised on a national scale and said future CQC inspections would focus on how NHS trusts learn following the deaths of their patients.

In a statement to Parliament today, Jeremy Hunt said he would be accepting all the recommendations in the report.

He added that from March 31 2017 all trusts will be required to collect and publish quarterly reports on how many deaths could have been prevented in their organisation and an assessment of why this might vary from the national average.

Trusts will also be required to appoint a board-level leader for patient safety director to take responsibility for collecting this data.

Hunt added: “I also – and this may surprise some in the House – expect to see an increase in the number of reported avoidable deaths. This is likely to be hospitals get better at spotting and reporting them than because care is deteriorating.

“We should also remember that when there is a tragedy in the NHS, there is always a second victim, namely the doctor or nurse involved who invariably suffers huge anguish.”

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