The Care Quality Commission (“CQC”) recently published its report, ‘Learning, candour and accountability’, which considers how acute, community and mental health NHS trusts review and investigate the deaths of patients in England. This report follows a review commissioned by the CQC last year which highlighted that fewer than 1% of deaths reported in learning disability services and 0.3% of all deaths in mental health services for older people had been investigated at a particular NHS Foundation Trust. The CQC report’s findings and recommendations provide helpful transferable guidance that may appropriately and beneficially be implemented more broadly in the policies and protocols of health and/or social care providers.

Identifying inconsistencies

The ‘Learning, candour and accountability’ review identified that the CQC was unable to identify any trust that could demonstrate good practice across every aspect of identifying, reviewing and investigating deaths and ensuring that learning is implemented.

Many patients receive care from multiple providers in the months before their death (including GPs, acute hospitals, community health services, and mental health providers). The report found that often there were no clear lines of responsibility or systems for the provider who identified a death to inform other providers or commissioners.

As the Serious Incident Framework is used by healthcare staff as the process to support decisions to review and/or investigate deaths, this means in practice that investigations will only be undertaken if the care provided to the patient has led to a serious incident being reported. The criteria for deciding to report as such an incident and application of the framework varied across trusts.

Additionally, the quality of investigations was found to be variable and healthcare staff are applying the methods identified in the framework inconsistently.

Families and carers were found to have a poor experience of investigations and were not consistently treated with respect and sensitivity. This was found particularly to be the case for families and carers of people with a mental health problem or learning disability.

Where investigations had taken place, it was found that there are no consistent systems to make sure recommendations were acted on or learning appropriately shared with others who could support the improvements needed.

A national priority

The CQC urged the Secretary of State for Health and all within the health and social care system to make learning from deaths a national priority to avoid missing opportunities to improve care.

The CQC recommended that a new single framework be developed on learning from deaths. This should complement the Serious Incident Framework and define good practice in relation to identifying, reporting, investigating and learning from deaths in care and provide guidance in respect of when an independent investigation may be appropriate. The framework should be developed in partnership with families and carers and define what they can expect from healthcare providers during the investigation process.

Lessons learnt

The CQC stressed that coordination is key. Following the review, health and social care providers and commissioners should implement systems to ensure that recommendations from reviews are acted upon on by all involved in the service user’s care.

More work is needed to ensure the deaths of people with a mental health or learning disability diagnosis receive the attention they need. Reviews and investigations should focus on system analysis rather than individual errors, and families and carers of the deceased should be given greater involvement.

If you have any questions regarding the content of this article, please contact our Health and Social Care or Public & Regulatory teams who have extensive experience in acting for health and social care providers. 

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Claire Whittle

Senior Associate

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Emma Dowden-Teale


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Posted on 21/12/2016 in Legal Updates

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