The CQC's recent review of how NHS Trusts investigate patient deaths - 'Learning, candour and accountability' - finds what many already suspected - i.e. that the quality of NHS investigations into patient deaths is very variable, with pockets of good practice but lots of room for improvement.
The review focuses on family/carer involvement, decision-making about which deaths to investigate, the quality of those investigations and the extent to which lesson learning is truly embedded in the process. It concludes that much more needs to be done to achieve consistently good practice in each of these areas.
The CQC makes a number of recommendations on how to bring about the necessary improvements, including developing a national framework on learning from deaths.
The CQC was asked by the Secretary of State for Health to look into how acute, community and mental health NHS Trusts across the country investigate and learn from patient deaths after a previous review highlighted that certain groups of patients - including people with a learning disability - may be less likely to have their deaths investigated than other groups.
The CQC's review included requesting information about patient deaths from all NHS Trusts in England (93% replied), carrying out site visits to a sample of 12 Trusts and hearing from over 100 families with direct experience of NHS investigations into patient deaths.
What did the CQC find?
In essence, the CQC found that learning lessons from patient deaths needs to be a greater priority for everyone across the NHS.
Key findings include:
Family/carer involvement - The gist of the review findings here is that there is considerable variation in the extent to which families/carers are involved in the investigation process. Whilst it often appears on paper that they have been involved, this often feels to them like only token involvement. Many described a poor experience of the process, feeling they were not listened to or kept up-to-date with progress of the investigation. This can lead to a loss of confidence in the investigation process.
When to report/investigate deaths - The review identifies a lot of variation across the NHS in the way organisations identify, report and then decide whether to investigate patient deaths. The criteria for when a death should be investigated are not being consistently applied and definitions on this are unclear. Deaths of patients in the community and/or with multiple providers involved in their care are highlighted as a particular issue, with evidence of confusion about who should coordinate investigations in these circumstances. Related to this, the review highlights the current lack of any statutory or other criteria for doctors reporting deaths to coroners, which leads to inconsistency of approach. The CQC suggests that the proposed medical examiner role - which would involve an independent clinical review of all deaths before they are registered - should be introduced without further delay.
Quality of investigations - The quality of NHS investigations into patient deaths is found by the review to be variable, both between Trusts and within Trusts. Common problems are lack of consistent approach to evidence gathering and to involving staff/families in the process, lack of clarity in investigation reports and important questions not being adequately explored. There continues to be too much focus on individual errors rather than system analysis. Factors identified as contributing to this include lack of specialised training and support and lack of protected time for staff to complete investigations.
Learning - The review queries the extent to which Trust Boards have effective governance arrangements in place to satisfy themselves about the robustness of investigations and the extent to which learning is being embedded in the organisation. It highlights the lack of guidance for Boards to follow to ensure that learning from patient deaths is shared and acted upon. The CQC suggests that Boards should consider nominating a non-executive director to lead on mortality and learning from deaths. It also highlights that the next phase of CQC inspections will include a new, specific reference to learning from mortality reviews and deaths in the key lines of enquiry for how 'well led' an organisation is. The review also queries the extent to which learning from patient deaths becomes truly embedded and highlights, for example, the practical difficulties of relying on written communications such as newsletters/intranet posts to share learning when staff are so busy with clinical commitments.
The CQC's review makes seven recommendations to improve how patient deaths are investigated in the NHS. The focus of these is on giving organisations a clearer national steer on when and how patient deaths should be investigated, and on changing the culture in organisations to ensure that this issue is given due prominence. It is likely that how patient deaths are investigated and learned from will be the subject of increasing scrutiny in CQC inspections going forward.
Based on the recommendations made in this review, the following may be in the pipeline:
- A new, single framework on learning from deaths - this would complement the existing Serious Incident Framework and would define good practice from the beginning to the end of the process, including identifying, reporting, investigating and learning from patient deaths.
- Guidance for families/carers - this would set out what families/carers can expect from healthcare providers in the investigation process.
- Accredited training for people undertaking investigations, as well as ensuring that investigations work is factored into job descriptions and training plans.
How we can help
Our national team of over 40 healthcare lawyers has extensive experience of supporting and advising health and social care providers in relation to patient deaths investigations, including:
- Advice on Duty of Candour requirements
- Terms of Reference for investigations into patient deaths
- Liaison with external bodies - e.g. CQC, commissioners, coroners
- Reviewing draft serious incident investigation reports/actions plans
- Advice on independent investigations - e.g. input on scope and draft findings
- Training for serious incident investigators and Duty of Candour workshops
- Clinical governance scrutiny to assess the effectiveness of incident investigations, organisational learning and Board leadership and culture on learning
- Inquest advice and representation
- Representation and support in relation to further investigations which may be linked to patient deaths, including HSE or police investigations.