• Sir Mike Richards says systems for reviewing deaths need a “overhaul” and were worse than expected
  • Calls for new national framework to be in place by April 2017
  • Substantial variation in rates of deaths receiving “initial review”

The NHS’s approach to investigating and reporting deaths is worse than thought and “needs an overhaul”, the chief inspector of hospitals has told HSJ.

A report into learning from deaths while in NHS care by the Care Quality Commission has found a series of flaws and inconsistencies.

Sir Mike Richards, the CQC’s chief inspector of hospitals, said: “The extent of the problems is more than I expected. The whole system [of investigating deaths] needs an overhaul at national level and local level.” He added that “there is not a single NHS trust that is getting it completely right currently”.

The long-awaited report found that nearly six in 10 acute trusts carried out “initial reviews” on under 1 per cent of inpatient deaths, while 10 per cent carried out reviews on more than half of inpatient deaths. An initial review is where a review is carried out to decide whether a serious incident warrants further investigation.

The CQC said that there were “inconsistencies in how decisions are made on whether to carry out a review or investigation after a patient has died” and that the variation does not relate to the number of deaths or size or location of trusts.

The review showed that acute trust inpatients and A&E, the median rate of deaths subject to an “initial review” to is 0.8 per cent. At mental health providers the rate is significantly higher with a median rate of 63.5 per cent of inpatient deaths given an initial review.

The CQC carried out the review on the request of the health secretary, following concern about deaths reporting and investigation at Southern Health Foundation Trust. It looked into five areas: the involvement of families and carers, identification and reporting of deaths; decision to investigate; conduct of investigations and learning from reviews. It found “concerns” in all five areas.

The CQC’s report calls for a new national overarching framework for what is expected from trusts. It says the current national standardised mortality review currently being overseen by the Royal College of Physicians should form a “cornerstone” of this framework.

However the CQC said the framework must make wider improvements to the way trusts carry out reviews and communicate with patients, other medical providers and their own boards. For example, currently there is no system in place to tell other care providers if their patient has died while another’s care.

Sir Mike revealed to HSJ that he thought it should be a “matter of a very few months to get [the national framework] in place and from April 2017 we should be seeing a significant change”. He added: “We don’t want people to wait, we think trusts can start thinking about [how to improve] to straight away. We need to give a message out right now to trusts that this needs to be given greater priority.”

Sir Mike said that from April 2017 the CQC will begin placing a greater emphasis on how deaths are investigated as part of its own trust inspections. These assessments form part of the CQC’s ‘well-led’ key criteria.

Asked whether there should be a statutory or contracted requirement to involve families in death investigations, Sir Mike said this was a “question for the framework to consider”. He said, though, that the system needed a “culture change” to ensure that there is greater openness with families of people who have died.

The report also calls on the “the secretary of state for health and all within the health and social care system, to make this a national priority”. It Health Education England should work with the new Healthcare Safety Investigation Branch and providers to ensure staff have the capability and time to carry out good investigations of deaths, after concerns were raised there is not sufficient “protected time” or specialised training.