Learning Disability Today
Supporting professionals working in learning disability and autism services

CQC reviewing how NHS trusts investigate and learn from deaths

CQC logoCare regulator the Care Quality Commission (CQC) is carrying out a review of how NHS trusts identify, report, investigate and learn from deaths of people using their services – with a particular focus on people with a learning disability or mental health problem.

This follows a request from the Secretary of State for Health, Jeremy Hunt, which was part of the government’s response to a report into the deaths of people with a learning disability or mental health problem in contact with Southern Health Foundation NHS Foundation Trust.

In December 2015, a report by Mazars criticised Southern Health for its failure to adequately investigate unexplained deaths. Since then, the CQC has issued a warning notice to the trust, saying it needs to improve its governance arrangements to ensure robust investigation and demonstrable learning following incidents and deaths.

The CQC’s review will consider the quality of practice in relation to identifying, reporting and investigating the death of any person in contact with a health service managed by an NHS trust; whether the person is in hospital, receiving care in a community setting or living in their own home.

Professor Sir Mike Richards, CQC’s chief inspector of hospitals, said: “Very many people are under the care of secondary healthcare services at the time of their death.

“For most, the care provided has prolonged their life, eased their suffering and helped them to die with dignity. However, this is not the case for everybody. Every year thousands of people under the care of NHS trusts die prematurely because their treatment or care has not been as good as it could have been. Healthcare workers might have failed to identify an illness that could have been treated, not provided the advice that might have prevented an illness developing, not made a life-saving intervention with a person who is critically ill or made some other error that contributed to a premature death.

“It is essential that, when this happens, NHS services identify and investigate the circumstances of these deaths so that staff can learn from them and reduce the likelihood of a similar event happening in the future. It is also essential that NHS providers are open and honest with the families and carers of people who die whilst under their care.

“CQC’s review aims to find out to what extent NHS trusts are learning organisations when it comes to investigating the deaths of people under their care and how well they support and engage with the families of people who have died.”

The CQC will be writing to all acute, community and mental health trusts seeking information about the number of deaths in their hospitals, how they decide which of these should be investigated and how they then carry out those investigations. It will also ask how they involve families and use the learning from those investigations to make improvements.

In addition, CQC will conduct phone interviews with 30 trusts to get more information and then visit 12 to get an in-depth understanding of their practices and processes. The review aims to look for examples of good practice as well as identifying problems.

The work will be supported by an expert advisory group. As part of this, and wider work, the CQC will involve families and organisations that represent them.

The findings will be published in a national report towards the end of the year.

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