Sharing lessons from avoidable deaths
The government has announced that Trusts will be required to publish estimates of how many patients may have died due to problems in their care. Making the NHS the first healthcare organisation in the world to publish such data.
The scheme is part of the government’s response to the CQC’s report Learning, Candour and Accountability which highlighted concerns around openness with families and lack of a single framework to identify, analyse and learn from patient deaths. For further information about the CQC report, see our e-bulletin ‘The NHS to publish data on avoidable deaths’.
Key elements of the scheme
The Department of Health estimates that Trusts will publish data on between 1,250 to 9,000 deaths, ranging from high-profile failures in care to cases where terminally ill patients die sooner than expected.
- Data will be published on a quarterly basis, by individual Trusts.
- Trusts will make their own assessment of the number of deaths due to problems in care.
- The data will neither be collated centrally nor be comparable. This is to allow Trusts to concentrate on learning from mistakes and sharing lessons within their organisations and locally.
- Families of patients will also be given full explanations over relatives’ deaths.
Publication of avoidable death data is the latest in a series of initiatives identified in National Guidance on Learning from Deaths (March 2017). The scheme has a broad remit: ‘patients who mayhave died’ due to ‘problems’ in care. This is likely to provide a reasonable size data-set for common themes to emerge, which should assist in identification of learning points. The additional scrutiny will probably result in an increased number of coroner’s inquests and potentially, claims for preventable deaths.
The CQC will be reviewing how well Trusts investigate and learn from patient deaths as part of the new annual well-led inspections being carried out. The CQC will focus on how well Trusts take into account the views of families and carers and will assesses how providers are ensuring they meet the new national guidelines when patients die. The new inspection approach also gives the CQC the option of analysing up to four reviews and investigations of recent deaths, and carrying out a review of Trusts’ policies on responding to deaths of patients in their care.
Mortality governance should by now be a priority for Trust Boards, who should have a policy in place for how the Trust responds to deaths of patients under its care. This should incorporate not only the National Guidance, but also the Serious Incident Framework.
The Health Service Safety Investigations Bill is currently passing through Parliament and will create the concept of a ‘safe space’ for NHS safety investigations. This will enable staff to be candid and open in the information they provide to a new Health Service Safety Investigations Body, as part of an independent investigation for the purpose of learning.
How can Capsticks help?
We provide advice and support on all aspects of 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 Levels 2 and 3 investigations, wider public inquiries and inquests.
We offer fixed fee external review of investigation reports or, in the most serious cases, can take on the role of lead investigator. We are currently supporting Trusts with the new style CQC inspection framework, including delivering board level training and challenging new style inspection reports (including the new Use of Resources reports) and associated ratings.
Our vast experience in the healthcare and inquest fields means that we are best placed to advise you in difficult and often high profile cases. If you require assistance in relation to a patient death or would like to discuss any related issues please contact: Philip Hatherall. Georgia Ford, Tracey Lucas or Ian Cooper.