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Systemic problems found in NHS patient death investigations

A new review has found ‘system-wide’ problems in the way the NHS investigates patient deaths, with family members often left in the dark about failures in care.
Connor_Sparrowhawk_tile-620.jpg

A new review has found system-wide problems in the way the NHS investigates patient deaths, with family members often left in the dark about failures in care

The review by the Care Quality Commission (CQC) highlights how NHS trusts in England are immediately on the defensive, with one family member telling the regulator they had more courtesy at a supermarket checkout following the death of their loved one.

The health watchdog identified a string of problems with the investigation process, including claims of a level of acceptance and sense of inevitability when people with a learning disability or mental illness died early.

One parent told the CQC: I was put in a room. I shall never forget what the nurse in the room

A new review has found ‘system-wide’ problems in the way the NHS investigates patient deaths, with family members often left in the dark about failures in care

Connor Sparrowhawk
Connor Sparrowhawk

The review by the Care Quality Commission (CQC) highlights how NHS trusts in England are ‘immediately on the defensive’, with one family member telling the regulator they had more courtesy at a supermarket checkout following the death of their loved one.

The health watchdog identified a string of problems with the investigation process, including claims of a level of acceptance and sense of inevitability when people with a learning disability or mental illness died early.

One parent told the CQC: ‘I was put in a room. I shall never forget what the nurse in the room told me. She said: "You have got to accept that his time has come." Bearing in mind my son was just 34 years old.’

Official investigations

Where deaths may have been prevented, NHS trusts carry out investigations to establish accountability, learn from mistakes and to explain to families what went wrong.

But the CQC said grieving families were not being included or listened to in official investigations into patient deaths.

They were also left without clear answers on what happened.

One family member told the CQC: 'I've had more courtesy at the supermarket checkout than I've had at the trust.'

Missed opportunities

The CQC said the NHS is also missing opportunities to learn from patient deaths. This means similar events may be repeated in the future, it warns.

CQC chief inspector of hospitals Sir Mike Richards said: 'Families and carers are not always properly involved in the investigations process or treated with the respect they deserve.

'We found this was particularly the case for families and carers of people with a mental health problem or learning disability, which meant that these deaths were not always identified, well investigated or learned from.

'While elements of good practice exist, there is not a single NHS trust that is getting it completely right currently.'

Particular focus

The assessment, which paid particular attention to deaths of patients with mental health conditions and learning disabilities, is based on evidence from visits to 12 NHS trusts, a national survey of all NHS providers and interviews and discussions with more than 100 families.

The authors examined 27 death investigations and found that only two of the reports contained a satisfactory response to the family or carers of the person who died.

Loved ones were not always informed or kept up to date about investigations – often causing them further distress.

Meanwhile, trust board members often do not interrogate or challenge information about patient deaths effectively.

Entirely preventable death

The investigation was commissioned by health secretary Jeremy Hunt following the review into the death of Connor Sparrowhawk, who died while being cared for at Southern Health NHS Foundation Trust.

The family of the 18-year-old, who had a learning disability and epilepsy, raised concerns about the way his death was being investigated.

Following their campaigning, an investigation concluded that his death was entirely preventable.

Mark Winstanley, chief executive at charity Rethink Mental Illness, said: 'Not only are people with mental illness still dying 20 years earlier than the rest of the population, but lessons are not being learned about why this is happening, which is often down to poor health monitoring and responsiveness by the NHS and the dismissive attitude of some health professionals towards people with severe mental illness.'

Mr Hunt is expected to accept all 18 recommendations set out in the report in a speech to the Commons today.

These include setting a national standard into how NHS trusts investigate deaths and appointing a senior board member at each organisation to lead on patient safety.


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