In December 2016 the CQC prepared a report called Learning, Candour and Responsibility which was critical of the way that Trusts respond to the death of patients under their care. In particular, the report highlighted failings in family liaison and the lack of method in identification of deaths to be investigated, as well as inconsistent reporting and missed opportunities to learn either locally or more widely from the circumstances of the death.
It’s discouraging to read the statement of the CQC that “we were unable to identify any trust that could demonstrate good practice across all aspects of identifying, reviewing and investigating deaths and ensuring that learning is implemented.”
In March 2017 the National Quality Board issued guidance to Trusts – National Guidance on Learning from Deaths – to assist with implementing policies and processes to ensure that deaths in care (potentially including patients discharged from hospital within the previous 30 days) trigger a standardised response involving case record review, investigation where appropriate, and systems to enable learning from the incident. Compassionate and candid involvement with the family should operate throughout.
It remains to be seen how the situation will change in practice but by now – October 2017 – all Trusts are expected to have in place their policies and systems addressing the new requirements. Whilst one might have hoped that such an obvious area for consistent, effective proactivity would have received attention before now, It is clear that an enormous amount of work has gone into this initiative by the CQC, NHS England, NHS Improvement, the Department of Health, the Royal Colleges and individual Trusts; and the benefits should be considerable for the bereaved family and future patients.
If the family have been more fully and considerately involved, there may be fewer death cases brought to a solicitor, which most would say is a better outcome. Medical lawyers who are instructed in the case of a ‘death in care’ should make themselves aware of the policy of the Trust concerned; which by now will be in the public domain. Any case record review or investigative reports should be disclosable documents and will contribute to clarity in the interests of all concerned.
