RCP comment. CQC calls for action to end missed opportunities to learn from patient deaths

In a report out today the Care Quality Commission (CQC) has raised significant concerns about the quality of investigation processes led by NHS trusts into patient deaths.

Responding to the CQC report, Dr Kevin Stewart Clinical Director of the RCP’s Clinical Effectiveness and Evaluation Unit (CEEU), said:

We welcome today’s report from the CQC on the investigation of deaths in NHS care.

The Royal College of Physicians is leading a national programme to develop a standard approach to reviewing case records of adult patients dying in acute hospitals. While the primary focus of CQC work is the investigation into deaths of patients with mental health and learning disabilities, our methodology could easily be adapted to other groups.         

We know that 92% of acute trusts in England already have a system in place for reviewing case records of patients who die (NCEPOD 2015), but these are varied and there is no standard national approach, making sharing of learning more difficult.

As a profession it is important that we are able to learn from breakdowns in care processes as well as good practice, even where death was inevitable.

We have been commissioned by the Healthcare Quality Improvement Partnership (HQIP) on behalf of the NHS Improvement Patient Safety team and the NHS in Scotland to lead a national mortality case record review programme (NMCRRP).  Working with trusts, the Improvement Academy, Academic Health Science Networks (AHSNs) in England, and Healthcare Improvement Scotland, the programme will pilot and subsequently role out standardised approach to investigating adult deaths in acute hospitals.

This initiative will not create a new measure to determine the definition of an avoidable death – the programme exists with the clear aim of learning and improving, rather than naming and shaming, or creating a new league table for trusts. The main focus of the programme is to identify system failures and to ensure that we are able to make care safer for patients in future. As a profession it is important that we are able to learn from breakdowns in care processes as well as good practice, even where death was inevitable. 

Having already been met with great enthusiasm by clinicians and healthcare leaders, it is pleasing to see this appetite and desire to improve reflected at this high level.

We look forward to working with the CQC and partners to further develop this work, and imbedding a new consistent approach to mortality across all trusts. As healthcare professionals, we have a duty to provide a high quality of care to patients in the last stages of life, ensuring that all deaths are good deaths.

Notes to editors

For more information please contact Morgan Evans, senior communications adviser, by phone +44 (0) 2030 751 468, or email morgan.evans@rcplondon.ac.uk