Nationwide review into how NHS trusts learn from deaths

CQC has called a national review into the ways that NHS trusts learn from deaths, if at all. The review has been called in the wake of the death of a mental health patient who drowned in a bath following an epileptic fit.

An inquest into the death of the individual found that neglect had been a contributory factor. A report commissioned by NHS England found that only 272 out of 722 unexpected deaths had been investigated over four years at Southern Health NHS Foundation Trust. The figures are alarming as they suggest that no action is being taken over some of the most extreme situations which denies the Trust the opportunity to learn from mistakes.

Professor Mike Richards, Chief inspector of hospitals said: –

“Every year thousands of people under the care of NHS trusts die prematurely because their treatment or care has not been as good as it could have been.”

CQC will initially inspect 12 NHS trusts to determine how deaths in hospitals and the community are investigated and followed up on. It will also look at the support provided to families of those who pass away.

Whilst it is right for the Trust to be criticised for failing to investigate avoidable deaths, the possible underlying causes of this failure should also be considered. Trusts operate in a fast-paced sector and are rarely offered the opportunity of internal reflection in light of increasing financial pressures. Further support should be offered to Trusts to enable them to place a focus on avoidable deaths including strategic analysis of how to best prevent similar scenarios that could be avoided in the future. We await the outcome of the review called by CQC to see how concentrated the practice of not following up on avoidable deaths truly is.

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