NHS failing to learn from patient deaths

By Jim Gladman, Solicitor, Clinical Negligence

A new report from the Care Quality Commission (CQC) has found that the NHS is missing opportunities to learn from patient deaths. The CGC also said that too many families are not being included or listened to when there is an investigation in to a patient’s death.

The CQC report has raised significant concerns about:

  • the quality of investigation processes led by NHS trusts into patient deaths
  • the failure to learn from deaths so that action can be taken to improve care for future patients and their families

Professor Sir Mike Richards, Chief Inspector of Hospitals, said:

“We found that too often, opportunities are being missed to learn from deaths so that action can be taken to stop the same mistakes happening again.”

This comes as no surprise to solicitors who represent the families of patients who have died in the care of the NHS. Opportunities to help future patients are lost, and families are not properly involved in investigations – or are left without clear answers.

The CQC’s review was carried out at the request of the Health Secretary following the findings of the NHS England commissioned report that looked at all mental health and learning disability deaths at Southern Health NHS Foundation Trust between April 2011 and March 2015. The report identified a number of failings in the way the trust recorded and investigated deaths. It highlighted that certain groups of patients, including people with a learning disability and older people receiving mental health care, were far less likely to have their deaths investigated by the trust.

Professor 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 the families and carers of people with a mental health problem or learning disability.”

“While elements of good practice exist, there is not a single NHS trust that is getting it completely right currently. An agreed framework needs to be established that sets out exactly what the NHS should do when someone dies and ensures that families and carers are fully involved and treated with respect.”

Alongside the national agreed framework to inform best practice, CQC identified the need for improvement in a number of areas, including:

  • Learning from deaths needs much greater priority within the NHS to avoid missing opportunities to improve care
  • Bereaved relatives and carers must receive an honest and caring response from health and social care providers and the NHS should support their right to be meaningfully involved
  • More work is needed to ensure the deaths of people with a mental health or learning disability diagnosis receive the attention they deserve

One person interviewed by the CQC said:

“The most toxic, damaging, compounding, devastating thing that happens is they drip feed you information. They give you a tiny closed off answer. Every single time a piece of information came through it raised another question, and another question, and another question.”

It was noted in the report that if NHS trusts were more open and honest about what had happened, and apologised for the death, the bereaved might not feel the need to make a legal claim.

We know that the relatives of the deceased seek legal advice because they want an explanation as to why their loved one died, and to prevent the same happening to someone else.

It is clear to us from our experience, and from discussions with other solicitors, that the same mistakes are being made by different NHS trusts and sometimes in the same trust time after time. We have seen the same errors made again and again by mental health NHS trusts in failing to prevent psychiatric patients from causing serious or fatal injuries to themselves.

As noted by the CQC, it is time for a change and action should be taken to prevent future deaths.

You should seek legal advice if you think that the death of a loved one may have been caused by medical error or mistake.

The medical negligence team at Switalskis can help you with this, and can offer advice and assistance if the coroner decides to hold an inquest. Call us on 0800 138 0458 or send us a message via the contact form below.