“A national review by the Care Quality Commission (CQC) has found that the NHS is missing opportunities to learn from patient deaths and that too many families are not being included or listened to when an investigation happens.
In a report published last week, the quality regulator has raised significant concerns about the quality of investigations led by NHS trusts into patient deaths and the failure to prioritise learning from these deaths so that action can be taken to improve care for future patients and their families.
CQC’s review looked at how NHS trusts across the country identify, report, investigate and learn from the deaths of people using their services. The review found that that is no consistent national framework in place to support the NHS to investigate deaths. This can mean that opportunities to help future patients are lost, and grieving families are not properly involved in investigations – or are left without clear answers.
The CQC’s review was carried out at the request of the Secretary of State for Health following the findings of the ‘Mazars’ report into the deaths of people with a learning disability or mental health problem who were being cared for by Southern Health NHS Foundation Trust. CQC was asked to review how NHS trusts across the country investigate and learn from deaths to find out whether similar opportunities to learn from patient deaths were being missed elsewhere. While the review looked at trusts providing acute, community and mental health services, it placed a particular focus on people with mental health conditions and learning disabilities.”