• CQC finds some staff are fearful of engaging with bereaved families
  • Also finds deaths in community possibly not being properly recorded
  • Chief inspector says pace of change not fast enough 

Trusts are not doing enough to review and learn from the deaths of their patients, a report from the Care Quality Commission has warned. 

The review, which assessed how trusts had responded to national guidance issued in 2017 on the learning from deaths process, also found NHS staff were fearful of engaging with bereaved families, while the deaths of patients in the community were possibly not being properly investigated. 

Chief inspector Ted Baker said that while some trusts were doing good work, the CQC was “concerned that we are still seeing the same issues persist in some NHS trusts”.

He added: “Cultural change is not easy and will take time. However, the current pace of change is not fast enough.

“NHS trusts need to use the findings of this report to remind themselves of the key drivers to improve learning from deaths, to build on progress made so far and to accelerate the changes needed.”

The quality watchdog’s report found some evidence community organisations were struggling because of poor integration with other organisations and guidance that is too “acute-focused”.

It also found some trusts are still not engaging with bereaved families meaningfully, in some cases because of a lack of training and a fear among staff of the consequences for them professionally.

The CQC has been reviewing trusts’ implementation of the guidance since September 2017. The learning from deaths process was established after concerns trusts were not learning from deaths of patients, particularly those with mental health and learning difficulties. This followed a review of Southern Health Foundation Trust and its handling of the death of Connor Sparrowhawk, who drowned in a bath aged 18 in July 2013.

His mother Sara Ryan told HSJ: ”Yet another report restating issues we know about. I don’t understand how this stuff is so difficult for trusts to get right when it boils down to the basics of being open, honest and human. There is something very wrong when families are raising serious issues that existing bodies should have identified, and the persistence of these issues is both worrying and simply not good enough.”

In its report, published today, the CQC said trusts varied in how they were implementing the guidance, with some finding it more difficult than others.

Referring to challenges community providers faced, the CQC noted: “These included the high number of deaths and the fact that these may not be serious incidents, for example deaths of people at the end of their lives in the normal course of events.

“The co-production group also suggested that it is sometimes difficult for a community-based service or mental health service to find out about the death if it occurs in the community in the first place.”

The regulator added care for a community patient can be provided by multiple organisations, but there is less guidance on how separate organisations should work together to learn from these deaths.

It said: “While it is usually clear whose care the person was under when they died, many trusts do not routinely record information about which other organisations were involved and what care they provided.”

Issues included poor relationships between different organisations, difficulties in sharing information between GPs, clinical commissioning groups, and providers, and concerns over data protection.

The CQC highlighted a number of good practices its inspection teams had seen, but it also warned in some trusts there was still only “ad hoc” engagement with families after a serious incident or complaint.

“More needs to be done to make sure that bereaved families and carers are involved from the start,” it warned, adding: “Inspection staff found that staff can sometimes be fearful of engaging with bereaved families and carers. Reasons for this could be linked to a lack of skills or confidence to contact bereaved families, a fear of adding to families’ distress and grief, a culture of blame and concerns about potential repercussions on their professional career.”

Singled out for good work was the Greater Manchester Mental Health FT, where the CQC found clear processes in place for how families were initially contacted, how they were given support, and how they were involved in investigations.

The CQC said it was important organisations had clear lines of responsibility for the learning from deaths process up to board level. It added staff needed “sufficient resources” and time away from clinical roles to do the work well.