Hospitals are failing to investigate far too many deaths and frequently ignore and exclude relatives of patients who have died, a major NHS inquiry has found.
The health service’s failure to properly look into deaths is “a system-wide problem” that means hospitals are not learning from their mistakes and thus stopping other tragedies from occurring, its report says.
The Care Quality Commission report, ordered by health secretary Jeremy Hunt, is scathing about hospitals’ shoddy and insensitive treatment of bereaved relatives’ requests for information and to be involved in an inquiry. One relative told the CQC that they encountered “more courtesy at the supermarket checkout” after their loved one’s death.
Prof Sir Mike Richards, the CQC’s chief inspector of hospitals, said: “Families and carers are not always properly involved in the investigations process or treated with the respect they deserve. We found this was particularly the case for families and carers of people with a mental health problem or learning disability which meant that these deaths were not always identified, well investigated or learnt from.”
Deborah Coles, director of the charity Inquest, which investigates deaths in custody, said the review of how hospitals respond to deaths had exposed “a defensive wall surrounding NHS investigations, an unwillingness to allow meaningful family involvement in the process and a refusal to accept accountability for NHS failings in the care of its most vulnerable patients”.
The CQC, the care watchdog for England, intends to overhaul how hospitals look into unexpected patient deaths or deaths owing to mistakes by staff. Investigations in future should be more thorough, more open and involve families much better, it promised.
Hunt told the CQC to undertake the inquiry after it emerged that Southern healthcare NHS foundation trust only investigated 1% of all deaths among patients with learning disabilities over a four-year period and even fewer – 0.3% – of those with mental health problems.
A review group the CQC set up to assess hospitals’ procedures said any relative should be told how and why their loved one had died.
“Yet throughout the review process we have heard from families who had to go to great lengths themselves to get answers to these questions, who were subjected to poor treatment from across the healthcare system and who had their experiences denied and their motives questioned,” said Dr George Julian, the regulator’s special adviser on family and carer experience. This was particularly the case for relatives of patients who had had either a mental health problem or learning disabilities.
One parent told the CQC: “I was put in a room. I shall never forget what the nurse in the room told me. She said, ‘You have got to accept that his time has come.’ Bearing in mind my son was just 34 years old.”
Katherine Murphy, the chief executive of the Patients Association, said the report confirmed that too many hospitals did not honestly and openly investigate complaints from relatives. “These families have already lived through heartbreaking times – watching their loved one pass away – and they simply should not then be treated with so little respect and consideration,” she said.
The review team based their findings on assessing how 12 NHS trusts responded to unexpected or unusual patient deaths or deaths where errors had occured, discussion with more than 100 families and a survey of all NHS trusts in England.
When the team reviewed 27 investigations hospitals had undertaken they found that the families’ views had been taken onboard in just three cases. Many relatives were not kept informed about how investigations were progressing, often causing further distress.
The Academy of Medical Royal Colleges, which represents doctors, will help the CQC draw up an agreed system for investigating unusual deaths. Coles said a truly independent investigation framework was needed to tackle head-on the dangerous systems and practices which were “costing people’s lives”.
Problems the CQC found included families’ involvement in investigations being merely “tokenistic”, the views of NHS staff being given greater weight than that of relatives and hospitals seeing family members as “antagonistic” if they sought too much information or involvement.
Hospitals fail too often to investigate deaths, NHS watchdog finds
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