CQC review into how trusts investigate deaths: What you need to know

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In June 2016, the Care Quality Commission (CQC) launched a review into how NHS acute, community healthcare and mental health trusts investigate deaths and learn from their investigations. 

Commissioned by NHS England, the review also assessed whether opportunities to prevent deaths have been missed.

The NHS Confederation was part of the review’s Expert Advisory Group, representing the views and experiences of its members and helping to inform the review process.

The CQC has now published the review’s final report, titled Learning, candour and accountability. It concludes that learning from deaths is not currently being given sufficient priority within the NHS, both nationally and locally.

Here’s an overview of what else the review found.

The findings

  • Currently no single framework setting out what should be done to ensure that learning from deaths is maximised.
  • The review was unable to identify a single trust currently able to demonstrate good practice across all aspects of identifying, reviewing and investigating deaths and ensuring that learning is implemented – however, the review did identify trusts that demonstrate good practice at individual steps in the investigation pathway.
  • Families and carers often have a poor experience of investigations and are not consistently treated with respect and sensitivity and honesty.
  • The extent to which families and carers are involved in reviews and investigations of their relatives varies considerably.
  • Variation and inconsistency in the way organisations become aware of the deaths of people in their care across the NHS.
  • No clear lines of responsibility or systems for the provider who identifies a death to inform other providers or commissioners.
  • No consistent process or method for NHS trusts to record when recent patients die after they have been discharged from the care of the service, either from an inpatient service or from receiving services in the community.
  • Electronic systems do not support the sharing of information between NHS trusts or with others who have been involved in a patients’ care before their death.
  • Criteria for deciding to report as an incident and application of the Serious Incident Framework varied across trusts, particularly the range of information that needs to be considered by individual clinicians and staff to identify any problems in care and escalate for further review or investigation.
  • In the absence of a single national framework that specifically supports the review and decisions needed for deaths, recognising them as a significant event that may need a different response to patient safety incidents, clinicians and staff are using different methods to record their decisions.
  • Significant issues with the timeliness of investigations and confusion about the standards and timelines stated in guidance.
  • A multi-agency approach to investigating is restricted by a lack of clarity on identifying the responsible agency for leading investigations or expectations to look across pathways of care.
  • No consistent frameworks or guidance in place across the NHS that require boards to keep all deaths in care under review or effectively share learning with other organisations or individuals

The recommendations

  • The health secretary and all within the health and social care system should make this a "national priority". The Department of Health, supported by the National Quality Board – in partnership with families and carers, professional bodies, royal colleges and the third sector – work together to review the findings and recommendations from the report and publish a full response. Action should then be taken to begin coordinating improvement work across multiple organisations.
  • The Department of Health and the National Quality Board, working with royal colleges and families, should develop a new single framework on learning from death. This should define good practice in relation to identifying, reporting, investigating and learning from deaths in care and provide guidance for when an independent investigation may be appropriate. This should complement the Serious Incident Framework and clearly define roles and responsibilities.
  • Specifically the framework should:

    • Define what families and carers can expect from healthcare providers when they are involved in the investigation process following a death of a family member or somebody they care for. This should be developed in partnership with families and carers.
    • Provide solutions to the range of issues we set out for people with mental health conditions or a learning disability across national bodies, including the royal colleges. This should aim to improve consistency, definitions and practices that support the reduction of the increased risk of premature death.
  • NHS Digital and NHS Improvement should assess how they can facilitate the development of reliable and timely systems, so that information about a death is available to all providers who have recently been involved in that patient’s care. They should also provide guidance on a standard set of information to be collected by providers on all patients who have died.
  • Health Education England should work with the Healthcare Safety Investigation Branch and providers to develop approaches to ensuring that staff have the capability and capacity to carry out good investigations of deaths and write good reports, with a focus on these leading to improvements in care.
  • Provider organisations and commissioners must work together to review and improve their local approach following the death of people receiving care from their services. Provider boards should ensure that national guidance is implemented at a local level, so that deaths are identified, screened and investigated, when appropriate and that learning from deaths is shared and acted on. Emphasis must be given to engaging families and carers.

'Powerful reminder of work still needed'

Responding to the report, the head of the NHS Confederation, Stephen Dalton, said: “The report's conclusions and the distressing stories which have informed them are a powerful reminder of the work still needed to understand how we can best serve families and loved ones who can be left devastated by an unexpected death. 

“Both national and local bodies in the NHS are committed to working with families and their representatives to improve how it deals with investigations resulting from unexpected deaths.  
“In the aftermath of an unexpected death there are often complex legal and organisational responsibilities to address but the priority must be that all families are treated with nothing short of total respect and compassion."

Find out more

Access the full report from the CQC website.

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