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Health rights lawyer welcomes CQC review into how NHS trusts learn from deaths

The circumstances around the deaths of vulnerable patients should be examined robustly to help avoid unnecessary deaths

Nurse wheeling a trolley

14 April 2016

Health rights lawyers Emma Jones has welcomed an announcement from the Care Quality Commission that it is to carry out a review of the quality of practice by NHS trusts when investigating the deaths of patients with learning disabilities or mental health problems.

The announcement follows a report into the deaths of vulnerable patients in the care of Southern Health Foundation NHS foundation trust which was published in December 2015.  The report found that the deaths of more than 1000 patients at the trust were not properly investigated.

The report noted that the investigation rate into the deaths of people with learning disabilities was 1%, and for people older than 65 with mental health problems, it was 0.03%.

The CQC review will consider the quality of practice in relation to identifying, reporting and investigating the death of any person in contact with a health service managed by an NHS trust; whether the person is in hospital, receiving care in a community setting or living in their own home. The review will pay particular attention to how NHS trusts investigate and learn from deaths of people with a learning disability or mental health problem.

While many people receive excellent care whilst under the care of NHS trusts this is not always the case, and vulnerable patients, such as those with learning disabilities who may have difficulty in communicating with health care, die prematurely.

When this happens it is important that the NHS analyses why this has happened so that staff can learn from the circumstances of a particular death, and reduce the chances of it happening again in the future.

The CQC will contact all acute, community and mental health trusts asking for information about the number of deaths in their services, how they decide which ones should be investigated, and how those investigations are carried out.   The CQC will also ask trusts how the families of patients who have died and whose deaths are being investigated are involved in the investigation process.

The CQC will visit 12 trusts to gain an in-depth understanding of their practices and processes as part of this review. The review findings will be published in a national report at the end of 2016.

Health rights solicitor and human rights partner at Leigh Day, Emma Jones, said:

“I am pleased that the CQC is going to look at the way the deaths of vulnerable patients are investigated and acted upon.  Many families approach us following the death of a relative because they feel they have been ignored by trusts when they try and find out about the circumstances of a relative’s death.

“I hope that the national review will produce some examples of good practice in the reporting of deaths that NHS trusts can adopt and put into practice as soon as possible.  Families deserve to know why their loved ones died, especially if they believe their deaths could have been avoided.”

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