Unexpected deaths review finds 'consistent failings' in trust's risk assessments

The probe, which reviewed the serious incident reports filed by staff at Northamptonshire Healthcare Foundation Trust after each death, also found inconsistencies in the way reports were written.

The review by Nene and Corby clinical commissioning groups also found that eight of the reports acknowledged problems with training staff in assessing the risk of patients self-harming, or outlined requirements for more training.

The CCGs said the author of one serious incident report appeared to be a senior clinician involved in the patient’s care, which the commissioners called “poor investigative practice”.

They added that because the trust did not provide them with copies of its serious incident policy, it was not possible to determine whether the provider had followed its process for completing internal investigations.

The CCGs’ review covers deaths and suicides identified by the trust as serious incidents between April 2014 and May 2015.

The review, contained in documents presented to Corby CCG’s board meeting on Monday, said: “There are inconsistencies within [the serious incident] reports.

“For example [one] investigation concluded ‘care on the ward was of a good standard’ and yet identified that care plans were not individualised, responsive or developed with patients…

“Some reports identified recommendations but no care delivery failings. This implies that there were failures which, while not identified in the root cause analysis, are implicitly acknowledged in the action planning.”

In reviewing the outcome of a third incident, the CCG team said it was not clear from the incident report what action had been taken by the trust to access previous records about the patient.

They suggested that doing this may have provided a better understanding of the patient’s risks.

The report for a fourth death indicated that trust staff were trained in specialist risk management training but that care planning remained “substandard”, and wider understanding of services by staff was poor.

While the review found the trust’s general approach to investigating such cases was “robust”, the authors said the provider’s processes would benefit from a greater focus on care failings rather than the “avoidability” of incidents.

The review team – comprising David Knight, senior quality improvement manager at Nene and Corby CCGs, and Dr David Smart, clinical director for mental health at the CCGs – made five recommendations. These included:

• the trust should review the terms of reference for investigations to focus on the root causes of care failings rather than determining the root cause of the patient’s death;
• it must ensure that staff involved in a patient’s care do not undertake the subsequent investigation; and
• the trust should ensure that recommendations are mapped to the analysis of care or service delivery failings.

The review said Northamptonshire Healthcare had accepted all of the review’s recommendations and it is developing an action plan. The trust was approached for comment.

The trust is Northamptonshire’s main provider of mental health and community services, serving a population of 710,000.