• CQC release report following review of investigation processes into patient deaths by NHS trusts
• Regulator expresses concerns that opportunities to learn from deaths are missed
• We welcome important report which exposes inconsistencies in practice. It’s vital that circumstances around a patient’s death are well understood, and if warranted, investigated to ensure lessons are learnt to improve quality of care

Today, the Care Quality Commission released its report following a national review about the quality of investigation processes led by NHS trusts into patient deaths.

The quality regulator has raised significant concerns about the processes undertaken by many trusts and the failure to prioritise learning from deaths so that action can be taken to improve care for future patients and their families.

The CQC’s review was carried out at the request of the Secretary of State for Health following the findings of the NHS England commissioned report into the deaths of people with a learning disability or mental health problem who were being cared for by Southern Health NHS Foundation Trust.

Responding to the CQC’s report on the way trusts review and investigate the deaths of patients, the chief executive of NHS Providers, Chris Hopson, said:

“When a person dies under NHS care, bereaved families and carers must be treated with honesty, respect and compassion.  It is also vital that the circumstances surrounding the person’s death are well understood and, if warranted, investigated to ensure that the NHS learns lessons that can improve the quality of care. Families need to know that the NHS will recognise and act on any failings in care to prevent them happening again.

“We welcome this important report from the Care Quality Commission. It exposes inconsistencies and variations in practice across the NHS and within trusts which mean opportunities to learn from deaths and improve care are being missed.

We need significant change at local and national levels to resolve this

 “There are particular problems identifying and investigating the deaths of people who were being helped by a number of different services at the same time for a range of often-complex conditions, and who died out of hospital. This is frequently the case for those receiving NHS mental health or learning disability services, reinforcing health inequalities.

“We need significant change at local and national levels to resolve this. 

“The CQC has identified some areas of good practice by trusts that can serve as examples for others to follow. The CQC has also recognised the commitment of NHS staff to making change happen.

“We look forward to supporting our members in working with the Department of Health and national bodies to develop the CQC’s recommendations into clear improvement in care and to ensure families feel they have always been treated with kindness and candour."