CQC to begin examining patient deaths

After its report on learning from deaths published in Dec 2016, the CQC is to begin reviewing up to four patient deaths in trusts where ‘concerns’ are…

Executive summary

Following its report on learning from deaths published in December 2016, the Care Quality Commission (‘CQC’) is to begin reviewing up to four patient deaths in trusts where ‘concerns’ are raised. This is part of CQC plans to strengthen how it monitors hospital mortality reviews.

In detail

In the report, ‘Learning, candour and accountability - A review of the way NHS trusts review and investigate the deaths of patients in England’, CQC chief inspector of hospitals Sir Mike Richards concluded that the  NHS’s approach to investigating and reporting deaths was worse than had been thought and required an overhaul. The report, carried out at the request of the Secretary of State for Health following concern about reporting and investigating deaths at Southern Health Foundation Trust, found that 60% of acute trusts only investigate 1% of inpatient deaths.

With calls for a new national framework to tackle inconsistencies and variations in practices, the CQC has just announced its intention to review up to four deaths of patients at individual trusts where it has received “concerns” about that trust from families, whistleblowers or through its own risk dashboard. A CQC inspection team will select at random the deaths to be investigated, but they will include a person with a learning disability and one with a mental health need, where these can be identified. They are currently consulting publicly, until 14 July, to obtain input on how the reviews should be triggered.

Through sources such as bereavement services, patient liaison services, Healthwatch, Parliamentary and Health Service Ombudsman investigation findings, the CQC has said that it will ‘find out what families and carers are saying’ and its own risk dashboard, CQC Insight, will include information on avoidable deaths, which trusts have been required to report since April 2017.

Since publication of the December report, changes to inspection processes mean that in its new annual well led inspections, trusts are asked how learning from mortality reviews is shared across the organisation. In addition, inspectors will interview staff and executives involved in investigating deaths, as well as families and carers. This approach currently applies to NHS funded learning disability services and all NHS trusts except ambulance trusts but the CQC plans to introduce a similar approach next year to GP practices, adult social care, independent healthcare providers and ambulance trusts.

Conclusions and implications

In a wider political environment where the debate around regulation and inspection is now framed by reference not just to the events at Southern Health but at other healthcare institutions too, no one should be surprised at this new initiative from the CQC, particularly in view of the conclusions which were reached in the report discussed above.

Whilst trusts and other bodies will welcome the learning opportunities which will inevitably arise from mortality reviews, continued pressures on resources coupled with anxieties about organisations embracing a blame-free culture are entirely understandable.

In order to assist clients to prepare for this new era, we would be delighted to work with trusts by carrying out an audit into any investigations which may have been conducted thus far. If you would like to explore this or to discuss any other options by which we may be able help ensure compliance and improve both patient safety and learning opportunities, please do not hesitate to contact us.  

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