Hunt to force trusts to publish avoidable deaths data

Mr Hunt made the announcement in the House of Commons following the publication of today’s Care Quality Commission review into learning from deaths that occur in the NHS. Mr Hunt said he was “accepting all their recommendations”.

He told MPs that he would lay new regulations in Parliament which will require trusts, from 31 March 2017, to collect a “range of specified information” on potentially avoidable deaths and serious incidents.

Each trust will have to estimate how many deaths could have been prevented and provide an “assessment of why this might vary positively or negatively from the national average”. Mr Hunt’s plan for local estimates of avoidable deaths was previously labelled as “meaningless” by Professor Nick Black, from the London School of Hygiene and Tropical Medicine.

In Parliament Mr Hunt announced he was backing down on some aspects of his plan saying he accepted it would not be “valid” to compare data between hospitals nor would he be setting “any target for reducing reported avoidable deaths”.

Trust’s will publish the data quarterly, along with evidence on what resultant “learning and action” has been taken‎, so that “local patients and the public can see whether and where progress is being made”. NHS Improvement will also be asked to collect this information at “a national level”.

It is unclear what information trusts will be asked to collect as part of the initiative but Mr Hunt said the methodology would be adapted by the Royal College of Physicians from work by Professor Nick Black and Dr Helen Hogan. HSJ has previously reported on work currently being piloted by the RCP to create a new national mortality case record review. As part of that, trusts are required to score inpatient deaths on a scale of one to six – from “definitely avoidable” to “definitely not avoidable”.

Other announcements included:

• NHS National Quality Board to draw up a standardised national framework before the end of March 2017 which is to be implemented by trusts from April 2017.
• All trusts to appoint a patient safety director at board-level to ensure learning from deaths is “prioritised”. Mr Hunt said this was likely to be a medical director.
• Investigations are to “genuinely involve families and carers” but he made no specific announcement on how he would like to see this happen. The new Healthcare Safety Investigation Branch is expected to develop a new exemplary model for investigation.
• Health Education England will be asked to review the training for all doctors and nurses to improve the way they engage with patients and families after a serious incident or death. HEE will also be tasked with ensuring that health staff get help to maintain their “resilience in extremely challenging situations”.
• The roll-out from next year of a Learning Disabilities Mortality Review Programme to ensure “standardised review of all learning disability deaths between the ages of 4 to 74”. The programme will be fully rolled-out by 2019.

In his speech, Mr Hunt paid tribute to Connor Sparrowhawk, whose death at Southern Health Foundation Trust in 2013, sparked the CQC review. He also praised Connor’s mother, Sara Ryan, for her “persistent and determined” efforts to ensure a full invesigation into his death.

He said it was thanks to her efforts that ”many improvements will be made to the care of people with learning disabilities and many lives saved”.