- Second inquiry launched into care failings at Liverpool Community Health Trust
- Further scrutiny needed for 17,000 patient safety-related incidents, including around 150 deaths
- Review to look at how senior leadership at former trust may have contributed to poor care
A second independent inquiry into the former Liverpool Community Health Trust has been announced by ministers this morning, and is expected to investigate around 150 deaths.
It will be led by Bill Kirkup, who completed a major review into the trust last year, which found it had sought to “conceal” serious care failings and multiple cases of patient harm between 2010 and 2014.
It also found there had been a widespread culture of bullying and harassment.
LCHT’s services were taken over by Mersey Care Foundation Trust in 2018, which has since conducted a major review of incident data and records held by the former trust, as recommended by Dr Kirkup.
In a statement, Mersey Care said it had identified 17,000 patient safety related incidents which it believes require further scrutiny because of “poor and inconsistent record keeping, data management and gaps in processes relating to HR investigations”.
It is understood this includes 150 deaths that were not properly investigated by LCHT. It is not yet known how many of those deaths were potentially avoidable.
The second review could also raise further questions for local commissioners, regulators, and the Care Quality Commission, after the first inquiry criticised them for failing to identify the seriousness of problems at the trust earlier.
Health minister Stephen Hammond said in a written statement: “This second review…will be conducted over three stages. Stages one and two will identify individual serious patient safety incidents that had not been reported or adequately investigated by Liverpool Community Health and undertake a series of historic, mortality reviews.
“Stage three will fully investigate those individual serious patient safety incidents identified from the previous stages to determine the scale of deaths and patient harm and identify local and national learning.
“The independent investigation will also advise regulators where, in the opinion of the panel, the systems, processes and senior leadership within the former Liverpool Health Community Trust may have adversely contributed to the safe delivery of patient care.
“This will not be a re-run of the previous independent review, but it will draw upon its findings as well as the new evidence identified by Mersey Care NHS Foundation Trust in its response to the recommendations of the original report. The independent investigation will engage with families of former patients and affected staff to understand their concerns to inform the work of stage three.”
The Mersey Care statement added: “Liverpool Community Services are now a completely different organisation and were rated as ‘good’ for caring and responsive in the most recent inspection from the Care Quality Commission earlier this year.
“We can assure staff and patients that those services are now safe and we have established robust quality assurance checks and governance in place.”
Joe Rafferty, chief executive of Mersey Care, told HSJ: “In our view, the way the trust reviewed patient safety incidents did not comply at all with the standard process - seven steps to patient safety - which was published in 2004.
“They used an approach that was more consistent with risk management rather than focussing on what happened to the patient. Normally you would record a level of patient harm, and sometimes they did that, but they were also recording things like financial impact and reputational harm. Sometimes things were considered very high risk even when there was no harm to the patient, and then other incidents were low risk even though someone had been seriously harmed.
“I think people at LCH thought they were doing something innovative by thinking about clinical, financial and reputational risks together. But it wasn’t implemented well, and it ended up being really harmful to patients because they weren’t learning from things.
“And then there was a hugely inappropriate system in place to record and manage the data, and an absence of any sort of central nerve centre to monitor patient safety and take a helicopter view. I would add, though, that it wasn’t entirely like this. We found some services which were exemplary.”
6 June 2019