Learning, candour and accountability: A review of the way NHS trusts review and investigate the deaths of patients in England (2016)

Summary

The Care Quality Commission is the independent regulator of health and adult social care in England. We make sure that health and social care services provide people with safe, effective, compassionate, high quality care and we encourage care services to improve.

Their role:

• They register health and adult social care providers.
• They monitor and inspect services to see whether they are safe, effective, caring, responsive and well-led, and we publish what we find, including quality ratings.
• They use our legal powers to take action where we identify poor care.
• They speak independently, publishing regional and national views of the major quality issues in health and social care, and encouraging improvement by highlighting good practice.

Content

This review was carried out in response to the very low numbers of investigations or reviews of deaths at Southern Health NHS Foundation Trust. Over a four-year period, fewer than 1% of deaths in Southern Health’s learning disability services and 0.3% of deaths in their mental health services for older people were investigated as a serious incident requiring investigation. 

Throughout this review, families and carers have told the CQC that they often have a poor experience of investigations and are not always treated with kindness, respect and honesty. This was particularly the case for families and carers of people with a mental health problem or learning disability.

However, there is currently no single framework for NHS trusts that sets out what they need to do to maximise the learning from deaths that may be the result of problems in care. This means that there are a range of systems and processes in place, and that practice varies widely across providers. As a result, learning from deaths is not being given enough consideration in the NHS and opportunities to improve care for future patients are being missed.

This reports sets out the next steps.