Report on patient deaths makes 'devastating reading'

A national review by the Care Quality Commission published today has found that the NHS is missing opportunities to learn from patient deaths and that too many families are not being included or listened to when an investigation happens.

The report raises significant concerns about the quality of investigations led by NHS trusts into patient deaths and the failure to prioritise learning from these deaths so that action can be taken to improve care for future patients and their families.

The review found that there is no consistent national framework in place to support the NHS to investigate deaths. This can mean that opportunities to help future patients are lost, and families are not properly involved in investigations - or are left without clear answers.

Responding to the report, Jane Mordue, Chair of Healthwatch England, said:

“When people die unexpectedly under the care of the NHS it can be hugely distressing for both families and staff. The only good that can ever come out of such incidents is that lessons are learnt so that others don’t ever have to suffer the same fate. This approach is absolutely vital for ensuring public trust in the health service.

“Today’s report therefore makes devastating reading. If the NHS is going to learn from mistakes then it first needs to know when and why things are going wrong, and the only way to do this is through carrying out thorough investigations. This can also help the relatives of those affected understand what has happened and give them the closure they need.

“Whilst there are examples of people doing some of the right things, it is simply unacceptable that not a single one of the NHS trusts involved were judged to exemplify the way investigations should be carried out from start to finish.

“Healthwatch across the country will wholeheartedly support the report’s focus on what people need from investigations rather than meeting the system’s arbitrary timescales and targets. Indeed much could be learnt from the wider work that has been done on complaints handling in the NHS, such as the ‘My Expectations’ framework, which aims to put people at the heart of the process by ensuring investigations are transparent, fair and compassionate.”

The regulator is now calling on its national partners to work together to develop a national framework, so that NHS trusts have clarity on the actions required when someone in their care dies. This will ensure that learning is promoted and used to improve care, and so that families are consistently listened to as equal partners alongside NHS staff.