Summary of recommendations Taking the learning from good practice, the CQC want to see tangible progress on four key areas. Below is a summary of the CQC's recommendations. People with a learning disability and or autistic people who may also have a mental health condition should be supported to live in their communities. This means prompt diagnosis, local support services and effective crisis intervention.People who are being cared for in hospital in the meantime must receive high-quality, person-centred, specialised care in small units. This means the right staff who are trained to support their needs supporting them along a journey to leave hospital.There must be renewed attempts to reduce restrictive practice by all health and social care providers, commissioners and others. We have seen too many examples of inappropriate restrictions that could have been avoided. We know in absolute emergencies this may be necessary, but we want to be clear – it should not be seen as a way to care for someone.There must be increased oversight and accountability for people with a learning disability, and or autistic people who may also have a mental health problem. There must be a single point of accountability to oversee progress in this policy area.
The report also confirms that the NHS serves as a ‘safety net’ for the private sector with around 6,000 people a year transferred to NHS hospitals following treatment in private hospitals.
Read the press release and coverage on BBC News, the Telegraph and Health Service Journal
Read a blog on patient safety from Peter Walsh
Sources of further information on patient safety private hospitals
Read a blog from Colin Leys exploring the issues in the report.
This is an independent review of the SLS:
1. To consider recommendations made by the State Coroner and by independent reviews conducted in response to the Chemotherapy Underdosing that relate to incident reporting and management.
2. To determine and describe how the SLS is used across SA Health for patient incident reporting and management including:
a. adoption and uptake;
b. data extraction;
d. incident management; and
e. open disclosure to patients and feedback to staff.
3. To identify factors that are impeding or may impede the use of SLS, including;
a. the culture of reporting and incident management, and
b. the availability and uptake of training and education.
4. To determine if Datix Web, the software platform used for the SLS, meets the needs of SA Health and whether its functionality is comparable to alternative programs.
5. To make recommendation to the Chief Executive (CE), Department of Health and Wellbeing that will assist in assuring robust incident reporting and management and the sharing of learnings across SA Health.
The new research maps the provision of safer custody telephone lines across the prison estate - dedicated phone lines which enable family members and others to pass on urgent information when they have concerns.
It finds that provision is patchy, under-resourced and even non-existent in some prisons, leaving families struggling to share their concerns with prison staff. The report reveals that:
Almost two in five (37%) prisons in England and Wales appeared to have no functioning dedicated safer custody telephone lines for families to get in touch.
Of these, nearly one in five prisons (18%) had no publicly advertised number for a dedicated safer custody telephone line.
A further 18% of prisons advertised a dedicated line, but when called the number either wasn’t operational, was not answered, or went through to a general prison switchboard.
Of the 75 dedicated safer custody telephone lines that went through to safer custody departments, only 13 (17%) were answered by a member of staff.
Over 80% of dedicated safer custody lines that went through to safer custody departments (62 prisons in total) put the caller straight through to an answer machine.
The majority of studies typically classify patient harm as preventable if it occurs as a result of an identifiable modifiable cause and its future recurrence can be avoided by reasonable adaptation to a process or adherence to guidelines.
At least 6% of patients experienced preventable harm across the healthcare service.
13% of the identified preventable harm causes prolonged or permanent disability or leads to death.
The main types of patient safety incidents which contribute to preventable harm are medication incidents, diagnostic incidents and incidents occurring following the receipt of suboptimal clinical management/therapies.
Despite the large number of studies included in this review, the quality and depth of data presented on preventable patient harm is very low. Preventability was reported as a secondary outcome across the vast majority of the studies – ie broadly, most of the studies were not focused on preventability.
Research to identify the major preventable sources of severe patient harm as well as the stages, the systems and the practitioners involved in the occurrence of preventable harmful incidents is needed.
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.