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Learning, candour and accountability: a review of the way NHS trusts review and investigate the deaths of patients in England
- Author:
- CARE QUALITY COMMISSION
- Publisher:
- Care Quality Commission
- Publication year:
- 2016
- Pagination:
- 76
- Place of publication:
- Newcastle upon Tyne
Reports on a review carried out by the Care Quality Commission to investigate how NHS trusts identify, investigate and learn from the deaths of people under their care. This review was carried out in response to the very low numbers of investigations or reviews of deaths at Southern Health NHS Foundation Trust. It draws on evidence from a national survey of NHS trusts and visits to 12 acute, community healthcare and mental health trusts; the views of over 100 families, collected through interviews, events and an online form; and consultation with charities and NHS professionals. The findings are discussed in five areas: the involvement of families and carers; the identification and reporting of deaths; making decisions to review and investigate; decisions to review or investigate; and governance arrangement and learning. Examples of promising practice are also included. The results found that that many carers and families had a poor experience of investigations and are not always treated with respect and honesty. This was especially true of deaths involving people with a learning disability or people with mental problems. The review also found that opportunities are missed to learn across the system from deaths that may have been prevented. It concludes that learning from deaths needs to be a much greater priority for all working within health and social care. The report makes recommendations for improvement. (Edited publisher abstract)