Our review of the way NHS trusts review and investigate deaths has found that opportunities to learn from patient deaths are being missed – and too many families are not being included or listened to when an investigation takes place.
Families: poor experience
Families and carers often have a poor experience of investigations. Our review found that they are not consistently treated with kindness, respect and honesty, despite many trusts saying that they value family involvement. We also found that the deaths of people with a learning disability or a mental illness do not consistently receive the attention they need.
The report highlights the need for learning from deaths to be given greater priority by all those working in health and social care. Without significant change at local and national levels, it argues, opportunities to improve care for future patients will continue to be missed.
No single trust demonstrates good practice in all areas of the process
While the review found areas of good practice at individual steps in the investigation pathway, no single trust was able to demonstrate good practice across all aspects of identifying, reviewing and investigating deaths and ensuring that learning was put into practice.
With no single framework setting out what should be done to ensure that as much as possible is learned from deaths, individual providers and commissioners have developed a range of systems and processes, and practice varies widely.
Making change a national priority
But while the report identifies widespread variation, it calls for the NHS and national bodies to recognise the need to improve the way deaths are investigated for the benefit of families and future patients, instead of singling out individual trusts for blame.
Professor Sir Mike Richards, our Chief Inspector of Hospitals, said: "Investigations into problems in care prior to a patient's death must improve for the benefit of families and, importantly, people receiving care in the future... This is a system-wide problem, which needs to become a national priority."
Among the report's recommendations, we call for our partners to work with us to develop a national framework, and for improvements in the way bereaved families and carers are involved in investigations.