The NHS to publish data on avoidable deaths
Following the sad death of Connor Sparrowhawk in 2013 at Southern Health NHS Trust, Jeremy Hunt asked the CQC to conduct a national review into the way NHS trusts investigate and learn from the deaths of patients in England.
The CQC visited a sample of 12 NHS trusts, produced a national survey of all NHS trusts providing acute, mental health and community services and undertook interviews with over 100 families and carers. That CQC report Learning, Candour and Accountability, has now been published. It concludes that many families do not experience the NHS as being open when a death occurs, and there is ‘no single framework which sets out how NHS organisations should identify, analyse and learn from the deaths of patients in their care.
As a result, Mr Hunt accepted the CQC’s recommendations, and announced that from 31 March 2017, all NHS Trusts and Foundation Trusts will be required to:
- collect and publish specified information on deaths, including an estimate of how many deaths could have been prevented;
- follow a national framework for identifying potentially avoidable deaths, reviewing the care provided, and learning from mistakes;
- identify a board-level leader as patient safety director, to take responsibility for this agenda (this is likely to be the medical director);
- appoint a non-executive director to take oversight of progress;
- ensure that investigations of any deaths are more thorough and kind, and genuinely involve families and carers;
- publish evidence of learning and action.
It is not yet known how a ‘potentially preventable death’ will be defined. This is likely to be both important and difficult, as it is often not straightforward to identify what did cause the death (particularly if your coroner will not disclose the post-mortem report to you).
What is next?
The NHS National Quality Board and Keith Conradi, Chief Investigator of Healthcare Safety, will produce mortality investigation guidelines before the end of March 2017, for implementation by all Trusts. We also await the outcome of the ‘safe space’ consultation.
In the meantime, we suggest Trusts:
- get involved in the design of the new mortality investigation framework, and
- ensure that the investigation into each death is thorough, and involves the family in a meaningful way and identifies the learning and actions taken as a result.
- consider what data about deaths you currently collect and how this can be adapted to produce your number of avoidable deaths.
Capsticks can help by providing advice and support on all aspects of your investigations of patient deaths including training, audit, associated inquests and claims and the evidence of learning required for well led organisations.
Capsticks has supported Trusts in the review of Level 2 and Level 3 investigations and in wider public inquiries. In particular, we offer a fixed fee external review of Trust investigation reports and for the most serious incidents can take on the role of Independent Lead Investigator for Level 2 or 3 investigations (drawing in independent clinical expert opinion as required). Our vast experience of clinical negligence, patient safety and candour means that we are best placed to assist in these difficult cases.