A national review by the Care Quality Commission (CQC) has found that the NHS is missing opportunities to learn from patient deaths and that too many families are not being included or listened to when an investigation happens.
In a report out today (Tuesday 13 December), the CQC has raised significant concerns about the quality of investigation processes led by NHS trusts into patient deaths and the failure to prioritise learning from these deaths so that action can be taken to improve care for future patients and their families.
CQC’s review looked at how NHS trusts across the country identify, report, investigate and learn from the deaths of people using their services. The review found that there is no consistent national framework in place to support the NHS to investigate deaths that may be the result of problems in care. This can mean that opportunities to help future patients are lost, and families are not properly involved in investigations - or are left without clear answers.
You can read the full report from the CQC here.
In response to the news Paul Farmer, Chief Executive of Mind, said:
“We are deeply concerned that the NHS is systematically failing to learn from the deaths of people in its care. There must be an investigation every time someone dies while in the care of the state, and families should always be involved in this process.
"It is vital that the NHS is transparent and accountable and every possible lesson learned to prevent future tragedies. When a person is at their most unwell and receiving treatment and support for their mental health, the very least they should expect is that they, their friends and their families, can trust in those providing their care.”