CQC Deaths Review underlines urgent need for action over NHS investigations

In December the Care Quality Commission (‘CQC’) published its review of the investigation of deaths in the NHS. The report is a damning indictment of how the NHS identifies, reports, investigates and learns from deaths of patients.

AvMA Chief Executive Peter Walsh was member of the Expert Advisory Group advising the CQC on the review. He said:

“The report goes further than any other so far in exposing the dire quality and inconsistency of many NHS investigations. The most shocking thing is the widespread failure to involve patients’ families in investigations when there has been a death.

“This is borne out by our own experience of supporting families. Many trusts are not complying with the Duty of Candour or the ‘Serious Incident Framework’ which is also meant to be mandatory. However we see little of no action being taken over this.

“As well as NHS trusts getting their act together, we need to see the CQC itself and NHS England taking robust action to clamp down on this.”

We are also concerned that in spite of the dire quality of local investigations, the Department of Health is planning to give NHS trusts radical powers to withhold information it discovers in investigations not only from public view, but from the very patients / families where treatment is subject to investigations. In fact, the proposals for introducing a ‘Safe Space’ in NHS investigations would actually prohibit the sharing of certain information – even if relevant to what happens to the patient.

We are calling for Mr Hunt to change his plans. The Healthcare Safety Investigations Branch (‘HSIB’) has great potential to improve investigations. However, as this report underlines, openness and honesty with families is absolutely essential.

Suppressing evidence about what happened to your loved one would prevent proper investigation and testing of evidence, and lead to a lack of trust in any NHS investigation.