Learning, candour and accountability

A review of the way NHS trusts review and investigate the deaths of patients in England

A year after a review commissioned by NHS England uncovered failings at Southern Health Foundation Trust, we look at how acute, community and mental health trusts across the country investigate and learn from deaths of people who have been in their care.

NHS England's commissioned review looked at all mental health and learning disability deaths at Southern Health NHS Foundation Trust between April 2011 and March 2015. The report identified a number of failings in the way the trust recorded and investigated deaths and highlighted that certain groups of patients including people with a learning disability and older people receiving mental health care were far less likely to have their deaths investigated by the trust. The Secretary of State for Health asked us to look at how acute, community and mental health NHS trusts across the country investigate and learn from deaths to find out whether opportunities for prevention of death have been missed, and identify any improvements that are needed.

We carried out site visits and surveys, and talked to families, health professionals and charities

We looked at the processes and systems trusts use to identify, investigate and learn from the death of a person using their services. We looked particularly closely at how trusts investigate the deaths of people with a mental health problem or learning disability.

To gather evidence we:

• carried out a national survey of all NHS trusts and visited 12 acute, community healthcare and mental health trusts
• engaged with over 100 families, holding interviews and events, as well as seeking views through an online form, our online community and social media
• consulted with charities and NHS professionals.

What we found: five key areas

We weren't able to identify any trust that demonstrated good practice across all aspects of identifying, reviewing and investigating deaths, and ensuring that learning is implemented. But we saw some trusts demonstrate promising practice at individual steps.

We focused on five key areas:

1. Involvement of families and carers
   We found that families and carers often have a poor experience of reviews and investigations, and are not always treated with kindness, respect and sensitivity. We found that the extent of their involvement in reviews and investigations varies and they are not always listened to.
    

2. Identification and reporting
   We found inconsistency in the way organisations become aware of the deaths of people in their care, with no clear systems for a provider that identifies a death to tell commissioners or other providers involved in the person's care. Other issues include the lack of a consistent way of recording the deaths of patients that have recently been discharged. We also found that electronic systems don't always support the sharing of information between NHS trusts and other services involved in someone's care.
    

3. Decision to review or investigate
   Healthcare staff use the Serious Incident Framework to help them decide whether a review or investigation is needed. But this can mean investigations only happen if a serious incident has been reported, and the criteria for deciding to report an incident and the application of the framework both vary. Clinicians are using different methods to record their decisions, definitions used to identify and report deaths are used inconsistently, and sharing information between providers is often difficult.
    

4. Reviews and investigations
   The quality of investigations is often poor and methods set out in the Serious Incident Framework aren't applied consistently. Specialised training and support aren't given to all staff carrying out investigations. There are problems with the timeliness of investigations and confusion about standards and timelines set out in the guidance. Where a number of agencies are involved, their ability to work together is restricted by a lack of clarity over which agency is responsible for leading the investigation, and they often work in isolation.
    

5. Governance and learning
   There are no consistent frameworks or guidance requiring boards to keep all deaths under review, and boards only receive limited information about the deaths of people using their services. When they do receive information, they often don't challenge the data effectively. Where investigations take place, there are no consistent systems to make sure recommendations are acted on or learning is shared. There's a lack of robust mechanisms to disseminate learning from investigations or benchmark beyond a single trust.
    

Our recommendations

Our recommendations are set out in more detail in our report, where we describe what action we recommend and which body should lead it. In summary, we've identified the need for improvement in the following areas.

• Learning from deaths needs much greater priority within the NHS to avoid missing opportunities to improve care.
• Bereaved relatives and carers must receive an honest and caring response from health and social care providers and the NHS should support their right to be meaningfully involved.
• Healthcare providers should have a consistent approach to identifying and reporting the deaths of people using their services and share this information with other services involved in a patient's care.
• There needs to be a clear approach to support healthcare professionals' decisions to review and/or investigate a death, informed by timely access to information.
• Reviews and investigations need to be high quality and focus on system analysis rather than individual errors. Staff should have specialist training and protected time to undertake investigations.
• Greater clarity is needed to support agencies working together to investigate deaths and to identify improvements needed across services and commissioning.
• Learning from reviews and investigations needs to be better disseminated across trusts and other health and social care agencies, ensuring that appropriate actions are implemented and reviewed.
• More work is needed to ensure the deaths of people with a mental health or learning disability diagnosis receive the attention they need.