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NHS trusts culture may hinder progress on learning from deaths, CQC warns


By Valeria Fiore
Reporter
19 March 2019

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NHS trusts failing to adopt a more open culture might take longer to make progress on learning from deaths, the CQC has warned.

In its Learning from Deaths – a review of the first year of NHS trusts implementing the national guidance report, the CQC said that some trusts made progress on the implementation of national guidance, introduced in 2017 to encourage trusts to take action on how they learn from deaths.

However, progress has been inconsistent and varies among trusts, the CQC said.

Problems with culture at some organisations might slow down the implementation of the national guidance, according to the CQC inspectors interviewed for this report.

Cultural change

The CQC based the finding of its report on interviews and focus groups with CQC inspectors and specialist advisors who headed ‘well-led’ inspections between September 2017 and June 2018.

The inspectors said that factors hindering learning from deaths ‘include a fear of litigation, public perception, or confrontation with families, and a failure to engage staff with the trust’s cultural values or empower them to raise concerns’.

Instead, organisations with a more open and transparent ‘no-blame culture’ focused on learning were quicker in developing processes to learn from deaths than NHS trusts with an ‘inward-looking, fearful culture’, according to the report.

The CQC also concluded that other factors, such as a clear and consistent leadership, positive relationships with other organisations, and support to staff with training and resources were helping trusts to be compliant with the guidance.

Trusts have been asked to improve processes for learning from deaths due to poor care and introduce strategies for how to communicate effectively and compassionately with bereaved families and carers following the National Quality Board (NQB) guidance, introduced in March 2017 and NQB guidance for trusts on working with families in July 2018.

‘We cannot lose momentum’

CQC’s chief inspector of hospitals professor Ted Baker said: ‘Through our well led inspections we have seen trusts that have made positive changes to ensure that learning from deaths is given the priority it deserves.

‘However, the speed of progress varies, and our review indicates that problems with the culture of some organisations are preventing sufficient progress. Cultural change is not easy and will take time, but we cannot lose momentum and the current pace of change is not fast enough.’

Professor Baker asked trusts to look into the good practice examples highlighted in the report, which he feels will help trusts ‘build on the progress’ made so far.

However, he said that trusts also need support from the top, ‘including support for behaviours that encourage more openness and learning across the NHS, clearer guidance for community and mental health trusts, and a more focused consideration of the progress being made on reviews and investigations of deaths of people with mental health problems or a learning disability.’

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