Progress on the recommendations from our review of how NHS trusts investigate and learn from deaths

This month marks a year since we published the findings of our thematic review ‘Learning, Candour and Accountability’ which identified specific concerns about the way NHS trusts were investigating and learning when patients within their care die and the extent to which families and carers were involved in the investigations process.

The review made seven recommendations to help to improve the quality of investigations and ensure safer services for future patients.

Since then, the Department of Health and the National Quality Board (NQB) has been leading a programme of work to implement those recommendations with input from a number of organisations, including CQC, NHS England, NHS Digital and NHS Improvement.

This programme of work has seen the development of new national guidance from the National Quality Board, of which CQC is a member. For NHS trusts the guidance sets out the actions they must take when someone in their care dies and clear reporting expectations requiring trusts to collect and publish specific information on patient deaths on a quarterly basis. Work to produce guidance for families and carers on what to expect from the investigation process is also underway.

Earlier this year we asked for feedback on our plans to strengthen the way we assess how NHS trusts providing acute, community and mental health services are learning from reviewing and investigating the deaths of patients.

Following feedback from over a hundred people and discussions at an NHS England family and carer workshop in November, we have developed an approach to reviewing how trusts investigate and learn from patient deaths that gives specific focus to the views of families and carers and assesses how providers are ensuring they meet the new national guidelines when patients die.

Our approach, which is being rolled out as part of our annual well-led inspections in NHS acute, community and mental health hospital trusts, also involves the option to analyse up to four reviews and investigations of recent deaths and a review of trusts’ policies on responding to deaths of patients in their care.

Professor Ted Baker, CQC's Chief Inspector of Hospitals, said:

“It has been a year since we published the findings of our thematic review and there has been good progress made by all organisations in implementing its recommendations. It is important that this work continues at pace and we are committed to playing our part in that process.

“The changes that we at the CQC have made to our inspection approach give closer scrutiny to the way in which NHS trusts identify patients who have died and decide which reviews or investigations are needed. They also involve a thorough review of how hospitals go about those investigations, how they ensure the involvement of families and carers, and how they share learning across the organisation to help drive improvements.

“The NHS is the first healthcare system to commit to reporting and publishing information on the number of avoidable deaths in its hospitals and the work that is being done by individual NHS trusts to learn from those deaths. This new level of transparency will be central to improving care and ensuring the safety of the NHS services we all rely on.

“We will use this information alongside the findings of our inspections to identify where providers must make improvements and to share good practice where we find hospitals that are doing it well.

“We can be proud of the progress made over the past year, but the challenge now is to deliver the full vision of a safer learning culture that was laid out in ‘Learning, Candour and Accountability so that learning from deaths becomes an accepted part of practice that provides answers for families and drives improvements in the quality and safety of care.”

The approach we have introduced for NHS trusts will be evaluated based on feedback we receive from the initial well led inspections to help inform our plans to introduce a similar approach for other sectors.

In the meantime we are continuing to work closely with NHS Improvement, NHS England, families and carers and NHS trusts as part of the wider programme of work being taken forward by the NQB.