NHS England is missing opportunities to learn from patient deaths and too many families are not being included or listened to when an investigation happens, according to a recent review by the Care Quality Commission (CQC).

The quality regulator has raised significant concerns about the quality of investigation processes 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.

Lost Opportunities

According to the review, there is no consistent national framework in place to support the NHS to investigate deaths that may be the result of problems in care. This can mean that opportunities to help future patients are lost, and families are not properly involved in investigations - or are left without clear answers.

The regulator is now calling on its national partners to work together to develop a national framework, so that NHS trusts have clarity on the actions required when someone in their care dies.

Calls for Change

“This report must be a wakeup call and result in concrete action,” commented Deborah Coles, Director of INQUEST and member of the Expert Advisory Group to the CQC Review. “It ratifies what INQUEST and families have been saying for years. There is a defensive wall surrounding NHS investigations, an unwillingness to allow meaningful family involvement in the process and a refusal to accept accountability for NHS failings in the care of its most vulnerable patients.”

“Political will and leadership is now required to drive change to a system which is not fit for purpose,” she added. “We reiterate that only an independent investigation framework can tackle head-on the dangerous systems and practises which are costing peoples' lives. A clear programme of action for 2017 must follow this report, to which families must be integral."

Criticism of NHS Investigations

The publication of the report has been welcomed by patient safety charity Action against Medical Accidents (AvMA), which has described the report a "damning indictment of how the NHS identifies, reports, investigates and learns from deaths of patients".

“The report goes further than any other so far in exposing the dire quality and inconsistency of many NHS investigations,” said AvMA Chief Executive Peter Walsh. “The most shocking thing is the widespread failure to involve patients’ families in investigations when there has been a death."

"This is borne out by our own experience of supporting families," he added. "Many trusts are not complying with the Duty of Candour or the ‘Serious Incident Framework’ which is also meant to be mandatory. However we see little of no action being taken over this. As well as NHS trusts getting their act together, we need to see the CQC itself and NHS England taking robust action to clamp down on this.”

AvMA has also raised concerns Department of Health plans to give NHS trusts radical powers to withhold information it discovers in investigations not only from public view, but from the very patients / families where treatment is subject to investigations. It claims that that the proposed introduction of a ‘Safe Space’ in NHS investigations would actually prohibit the sharing of certain information, even if relevant to what happens to the patient.

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