In 2015, NHS England commissioned a review into the Southern Health NHS Foundation Trust. It was concerned about how the Trust investigated the deaths of mental health patients and those with learning disabilities. It focused on the period between April 2011 and March 2015. Sadly the result of the report identified a number of failings including the way deaths were recorded and investigated.
The report highlighted that certain groups of patients, including those with learning disabilities and older people with mental health issues, were far less likely to have their deaths investigated.
As a result, the Care Quality Commission was tasked with looking at NHS facilities across the country and how they could learn from deaths within these vulnerable groups and discover whether opportunities to prevent deaths had been missed.
Sadly, the CQC recent findings were startling:
- Families and carers were not always treated with kindness, respect and sensitivity. They were not involved and were not always listened to. One relative told the CQC that they encountered “more courtesy at the supermarket checkout” than after their loved one’s death.
- There was inconsistency in the way organisations became aware of the deaths of people in their care. There were no clear systems to identify deaths and to inform the people providing the particular patient’s care. There was no real guidance to assist staff to decide whether a review or an investigation was needed in relation to the death and no continuity across the NHS.
- The quality of investigations was often poor. There was a lack of training and support given to staff carrying out the investigations.
- There is no consistent framework or guidance requiring NHS hospitals and facilities to keep all deaths under review. Surprisingly, many Boards receive little information regarding the deaths of people using their services.
The CQC report recommended that NHS facilities must learn from the deaths of patients in their care as it is missing opportunities to improve upon the care that it provides. Bereaved relatives and carers are entitled to receive an honest and caring response from health and social care providers. Greater clarity is needed to support agencies to work together to investigate deaths and to identify improvements needed across services.
It is clear that more work is required to ensure that the deaths of these vulnerable people receive the proper attention. More work is also needed to ensure that Health and Social Care agencies learn from these deaths.
The CQC now intends to overhaul how hospitals investigate unexpected patient deaths. Inquiries in future are to be more thorough and open.
The message is clear. If you have watched a love one pass away, you should be treated with respect, dignity and consideration.
For more information about Kate and her work, please click HERE.