The Care Quality Commission report

13th December 2016

A major NHS inquiry has found that hospitals are failing to investigate far too many deaths and frequently ignore the concerns of bereaved relatives.

The report, commissioned by NHS England, looked at the processes and systems hospital trusts use to identify, investigate and learn from the death of a person using their services. It found, amongst other issues, that families and carers often have a poor experience of reviews and investigations, and are not always treated with kindness, respect and sensitivity. Inconsistencies in the way organisations become aware of patient deaths were also identified, with no clear systems in place to govern how service providers identify a death and then inform commissioners or other providers involved in the person’s care.

According to the Care Quality Commission (CQC), the ‘system-wide problem’ means that hospitals are not learning from their mistakes, and are therefore failing to prevent other tragedies from occurring.

To stop these mistakes from happening in the future, the report recommended that:

  • Learning from deaths needs greater priority within the NHS to avoid missing opportunities to improve care.
  • Bereaved relatives and carers must receive an honest and caring response from health and social care providers, and the NHS should support their right to be meaningfully involved.
  • Healthcare providers should have a consistent approach to identifying and reporting the deaths of people using their services and must share this information with other services involved in a patient’s care.
  • There needs to be a clear approach to support healthcare professionals’ decisions to review and/or investigate a death, informed by timely access to information.
  • Reviews and investigations need to be of high quality and should focus on system analysis rather than individual errors. Staff should have specialist training and be allocated time to undertake investigations.
  • Greater clarity is needed to support agencies working together to investigate deaths and to identify improvements needed across services and commissioning.
  • Learning from reviews and investigations needs to be better disseminated across trusts and other health and social care agencies, ensuring that appropriate actions are implemented and reviewed.
  • More work is needed to ensure the deaths of people with a mental health or learning disability diagnosis receive the attention they need.

Christian Beadell, senior solicitor at Fletchers Solicitors, said:

Hospital death rates are an important measure of performance and have been subject to government review for a number of years. This report from the CQC switches the focus from a cold analysis of the figures to look at the management of the process itself. It is no surprise to see that the CQC has found failings in the way trusts investigate deaths and, and how they learn from any mistakes that occur.

In our experience, in the immediate aftermath of a death in a hospital, there are inconsistencies in the way this is dealt with by different trusts. Whilst there are processes for investigating and gathering information at the earliest stage, often this does not happen and it is left to the families to complain or press for coroner involvement to obtain vital answers. This should be something that the Trust actively seeks out in all cases.

However, in an overstretched NHS, the time and effort that needs to be expended in investigating a death can be barely spared. Yet, if patient safety and dignity is to be preserved, it is vital that errors are identified and the time found for a careful and considered review to take place. Learning from past experiences is a vital component for building a better future for our health service.

The full report can be found here:



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