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Watchdog report finds NHS hospitals are failing to properly investigate deaths


    Inquest Solicitor Ali Cloak considers the recent inquiry by the Care Quality Commission, the independent health and social care regulator, which has identified system-wide failures in respect of the investigation of patient deaths.

    By Ali Cloak

In December 2016, the Care Quality Commission (CQC) published its report ‘Learning, Candour and Accountability’. The inquiry into the way NHS Trusts review and investigate patients deaths, was commissioned by NHS England and the report is the culmination of a year’s investigation.  Health Secretary, Jeremy Hunt, ordered the inquiry following a number of high profile cases concerning preventable deaths in NHS Trusts.

The inquiry

Following the tragic death of Connor Sparrowhawk in July 2013, Southern Health NHS Foundation Trust were subject to an investigation of all mental health and learning disability deaths at the Trust between April 2011 and March 2015.

The Trust eventually accepted full responsibility for the death of the 18 year old who drowned in a bath at one of its facilities. However, initially, the hospital had classified Connor’s death as a result of natural causes but, following campaigns by his family, a full investigation concluded that his death was entirely preventable and that there had been failures in his care. Ultimately, it was found that the Trust’s neglect had contributed to Connor’s death.

The investigation, which concluded in December 2015, found that only 272 of the 722 deaths in the Trust over the previous 4 years had been properly investigated, and my colleague has written about this previously. Thereafter, the Health Secretary ordered a wider review in to how NHS Trusts in England investigate deaths.

The full CQC inquiry, conducted in 2016, consisted of a national survey of all NHS Trusts as well as a number of site visits. It included a mixture of acute, community and mental health Trusts, in addition to wider involvement with families, charities and NHS professionals.

Report findings

The CQC summarised their findings in five key areas:

1. Involvement of families – Family members and carers were not always fully involved in the investigation following the death of a loved one and many had poor experiences, with some not being treated with kindness, respect or sensitivity.

2. Identification reporting – There was much inconsistency in the way that deaths were notified and there was no clear system for a health provider to inform commissioners or other providers involved in that persons care. Inconsistencies were also identified in the way that patient deaths were recorded where the patient had recently been discharged home.

3. Inconsistency as to whether a death should be reviewed or investigated – There were varied criteria for reporting an incident and so clinicians were using different methods to record their decisions.

4. Quality of investigation – The CQC found that the quality of investigations was often poor and that recommended methods are not applied consistently. Specialised training is poor and not given to all staff carrying out investigations.

5. Governance and learning – The report identified a lack of framework reviewing information about hospital deaths. Data is not reviewed or checked consistently and so learning opportunities are missed and recommendations are not shared between professionals/trusts.


The CQC report sets out a number of recommendations for improving the way in which NHS Trusts investigate hospital deaths in England, as follows:

  • The NHS must prioritise learning from deaths in order to avoid mistakes being repeated and missing opportunities to improve care that is provided.
  • Relatives and carers of the deceased ought to receive an honest and caring response from the health professionals involved.
  • Healthcare providers should be consistent in the approach to identifying and reporting the deaths of service users.
  • There needs to be better dissemination of information between Trusts and other health and social care organisations to ensure that appropriate action is implemented and reviewed.
  • Deaths of people with a mental health or learning disability diagnosis need to be considered much more carefully than they currently are.

Jeremy Hunt has responded to the report by stating that rules would be published setting out how cases should be identified and looked into.

As a lawyer who often acts for bereaved families in inquests or claims following the death of a loved one, I am fully supportive of the recommendations highlighted in the CQC report and sincerely hope that changes are implemented to ensure that needless deaths are avoided and that families are treated with respect where a loved one has died and receive a full and proper investigation.

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