CQC review of deaths of NHS patients
Jeremy Hunt on the Care Quality Commission's report into the way NHS trusts review and investigate the deaths of patients in England.
This year, I asked the CQC to conduct an investigation into lessons that needed to be learned following the tragic death of Connor Sparrowhawk in 2013 at Southern Health NHS Trust. I want to start by paying tribute to his family, and particularly his mother Sara Ryan, for her persistent and determined campaigning for a proper investigation into what happened. The lessons of Mid Staffs, Morecambe Bay and indeed other injustices like Hillsborough is that when families speak out we must listen. And in this case thanks to Dr Ryan’s efforts many improvements will be made to the care of people with learning disabilities and many lives saved.
I asked the CQC to look at what happened at Southern Health NHS Foundation Trust but also to assess more broadly what lessons there are for the NHS as a whole. Their findings make sobering reading. Among other things, the report said:
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Families and carers often have a poor experience of mortality investigations; are sometimes not treated with kindness, respect and sensitivity; can feel their involvement is tokenistic; and often question the independence of the reports.
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The NHS does not prioritise learning from deaths and misses countless opportunities to learn and improve as a result.
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There is no single framework which sets out how local NHS organisations should identify, analyse and learn from deaths of patients in their care or who have recently been in their care.
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As a result there is inconsistency. Some NHS Trusts get some elements of mortality reporting right, but not one gets all elements right.
In particular, the leaders of NHS organisations, their doctors, nurses and other staff simply do not have access to the full picture of how many patients die in their care, which deaths were preventable and what needs to be learned.
I would like to thank the Professor Sir Mike Richards and his CQC colleagues for an extremely thoughtful and thorough report. Today I’m accepting all their recommendations.
So from March 31 next year the Boards of all NHS Trusts and Foundation Trusts will be required to:
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Collect a range of specified information on deaths that were potentially avoidable and serious incidents and consider what lessons need to be learned on a regular basis. This will include estimates of how many deaths could have been prevented in their own organisation and an assessment of why this might vary positively or negatively from the national average, based on methodology adapted by the Royal College of Physicians from work by Professor Nick Black and Dr Helen Hogan.
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We will be requiring Trusts to publish that information quarterly, in accordance with regulations I will lay before the House so that local patients and the public can see whether and where progress is being made.
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Alongside that data, they will publish evidence of learning and action that is happening as a consequence of that information.
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They will feed the information back to NHS Improvement at a national level, so that the whole NHS can learn more rapidly from individual incidents.
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All Trusts will be asked to identify a board-level leader as patient safety director to take responsibility for this agenda and ensure it is prioritised and resourced within their organisation. This person is likely to be the medical director. They will be asked to appoint a non-executive director to take oversight of progress.
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We will ensure that investigations of any deaths that may be the result of problems in care are more thorough and genuinely involve families and carers.
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More broadly instead of the patchwork approach we have currently, all Trusts will be asked to follow a standardised national framework for identifying potentially avoidable deaths, reviewing the care provided, and learning from mistakes.
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I have asked the NHS National Quality Board, which includes senior clinicians from all national NHS organisations, to draw up guidance on reviewing and learning from the care provided to people who die, in consultation with Keith Conradi, the new Chief Investigator of Healthcare Safety. These guidelines will be published before the end of March next year, for implementation by all Trusts in the year starting next April. We will also be working with the National Quality Board to ensure that much greater support is offered to bereaved families in the future.
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Because the report highlighted issues around the support given to families, Health Education England will be asked to review the training for all doctors and nurses with respect both to engaging with patients and families after a tragedy and – equally importantly - maintaining their own mental health and resilience in extremely challenging situations.
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And finally, because the report identified particular concerns about the treatment of people with learning disabilities, we will take two further actions: a) In acute trusts we will ask for particular priority to be given to identifying patients with a mental health problem or a learning disability to make sure their care responds to their particular needs; and that particular trouble is taken over any mortality investigations to ensure wrong assumptions are not made about the inevitability of death. b) We will also ensure that the NHS reviews and learns from all deaths of people with learning disabilities, in all settings. The Learning Disabilities Mortality Review Programme will provide support to both families and local NHS areas to enable reporting and independent, standardised review of all learning disability deaths between the ages of 4 to 74. We will ensure that there is coverage in all regions by the end of next year and full national roll out by 2019. As the programme develops, all learnings will be transferred to the national avoidable mortality programme. I have today asked the LeDeR programme to provide annual reports to the Department of Health on its findings and how best to take forward the learnings across the NHS.
From next year we will then become the first country in the world to publish data on avoidable deaths at a hospital by hospital level.
And I want to address the issue of how we ensure data published about avoidable deaths is accurate, fair and meaningful and ensure that the process of publication rewards openness and honesty
Of course we will be working closely with the CQC, NHS Improvement and senior NHS doctors and nurses to get this right. But I want to make clear to the House that I will not be setting any target for reducing reported avoidable deaths. Nor do I believe it will be valid to compare numbers between hospitals because the data depends on clinical views which may change or vary.
I also – and this may surprise some in the House – expect to see an increase in the number of reported avoidable deaths. This is likely to be hospitals get better at spotting and reporting them than because care is deteriorating.
We should also remember that when there is a tragedy in the NHS, there is always a second victim, namely the doctor or nurse involved who invariably suffers huge anguish. So let us today also give credit to all NHS frontline staff for the changes that are already taking place to improve patient safety:
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The number of people, for example, experiencing the four main hospital harms down by a third since November 2012.
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MRSA and CDiff rates halved since 2010.
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We have 10,000 more hospital nurses on our wards since the Francis report, now at record numbers.
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There is a new Healthcare Safety Investigations Branch to perform speedy, no-blame enquiries into avoidable harm and death modelled on the successful system that has operated in the airline industry for many years.
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And a consultation concluding this week on legislation to create a ‘safe space’ for NHS staff to talk openly about how to improve the safety of care for patients without having to worry about litigation or professional consequences.
Mr Speaker, the culture of the NHS is changing following a number of tragedies. But this report shows there is much progress to be made in the collecting of information about unexpected deaths, analysis of what was preventable and learning from the results. Only by implementing its recommendations in full will we honour the memory of Connor Sparrowhawk and I commend this statement to the House.