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.
This policy covers how Dorset Healthcare (DHC) University NHS Foundation Trust responds to patient deaths in care generally, not just those amounting to 'serious incidents', which will continue to be dealt with under the existing NHS Improvement’s 2015 'Serious Incident Framework'.
In this report the CQC have seen much good and outstanding care, in particular around:
staff interactions with patients
leadership and engagement with staff and patients.
However, there were a number of areas where services needed to make substantial improvements:
NICE's role is to improve outcomes for people using the NHS and other public health and social care services. They do this by:
Producing evidence-based guidance and advice for health, public health and social care practitioners.
Developing quality standards and performance metrics for those providing and commissioning health, public health and social care services.
Providing a range of information services for commissioners, practitioners and managers across the spectrum of health and social care.
This website will link into all NICE Guidelines.
MEs are a key element of the death certification reforms, which, once in place, will deliver a more comprehensive system of assurances for all non-coronial deaths, regardless of whether the deceased is buried or cremated. MEs will be employed in the NHS system, ensuring lines of accountability are separate from NHS Acute Trusts but allowing for access to information in the sensitive and urgent timescales to register a death.
This case study outlines the approach of South Tees Hospitals NHS Foundation Trust as one of the early adopter sites.
To date, the following learning points have been identified and explored:
End of Life Care, ceilings of care and avoidable admissions
Some investigations have highlighted cases where the End of Life Care pathway could have either been established or fully implemented, where this would have been of benefit to patients and their families. Some patients may not have been cared for in the right location, and some admissions could have been avoided if the End of Life Care pathway had been suitably established and followed.
Early detection and response to physiological deterioration, and effective communication
Response stretched by implementation of National Early Warning Score (NEWS) but still learning around effective communication of escalation. The use of standardised communication tools is essential.
Record keeping and organisation of medical records
Some learning was identified in relation to the accuracy and completeness of medical records. It was evident that not all records are reflective of the clinical picture.
Discussion with specialty teams is vital to support the investigation
An independent review by the ME should be further supported by speciality ‘experts’, and if possible, peer review from other trusts can be sought to allow for full independent review. Seeking speciality opinion from those not directly involved with the case within STHFT has also been shown to be effective.
Pathways for links to wider clinical governance processes have been strengthened.
Both the 2019/20 CCG and PSS CQUIN schemes comprise indicators, aligned to four key areas, in support of the NHS Long Term Plan.
Prevention of ill health
Best practice pathways
This document sets out the:
Overview of quality and safety indicators
Specialised Services Scheme
Scheme Eligibility and Value
Rules and Guidance - Agreeing and Implementing a CQUIN Scheme
This guidance aims to help the NHS to create an environment to better support staff when things go wrong and to encourage learning from incidents. Key challenges include:
equity and fairness
bullying and harassment.