The Care Quality Commission Report

The Care Quality Commission Report “Learning, Candour and Accountability”. Hannah Carr looks at the findings of today’s Care Quality Commission (CQC) Report and what this means for patients and patient safety.

Last year, a major NHS inquiry  found that hospitals are failing to investigate far too many deaths and frequently ignore the concerns of bereaved relatives.  A year later the Care Quality Commission (CQC) carried out its own review.

This review looked at the processes and systems hospital trusts use to identify, investigate and learn from the deaths of people in NHS care.  Of the 495,309 deaths registered in England last year, 47% of those people died in hospital, with even more dying while receiving services provided by NHS trusts as an outpatient or from community services provided by the trust.

It found, amongst other issues, that families and carers often have a poor experience of investigations and “are not always treated with kindness, respect and sensitivity”.  Further, that there were inconsistencies in the way organisations become aware of deaths of people in their care across the NHS, 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.

Whilst healthcare staff understand the expectation to report patient safety incidents, it appears from the CQC review, that investigations will only commence if the care provided to the patient has led to a serious incident being reported.  Due to variation in the criterion for deciding to report the incident across the various trusts, this has led to limitations in the ability to monitor, audit or regulate decision making processes in relation to reviewing deaths.

According to the CQC  the ‘system-wide problem’ means that hospitals are not learning from their mistakes.  The CQC goes on to explain that “learning from deaths needs to be a much greater priority for all working within health and social care.  Without significant change at local and national levels, opportunities to improve care for future patients will continue to be missed”.

With this in mind the CQC has identified the need for improvement in the following areas:

• 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.

Hannah Carr, associate solicitor at Novum Law, said in a response to the review:

“In an already overstretched NHS the time and effort required to investigate, report and learn from deaths places a considerable burden on all stakeholders involved.  However, patient safety is paramount and so it is vital that learning from deaths within a consistent framework needs to be given priority.  Learning from past experiences is vital for building a better and safer future for our health service.”

The full report can be found here