Learning from patient deaths and safety incidents

23 May 2016

The Care Quality Commission (CQC) has recently issued a warning notice to Southern Health NHS Foundation Trust requiring further improvements to its services, in order to protect patients at risk of harm and improve opportunities to learn from safety incidents. 

The Trust provides a range of mental health, learning disability and community services, in the South of England.  An earlier independent report commissioned by NHS England raised serious concerns about the way in which the Trust reported and investigated unexpected patient deaths.  The report also noted that the Trust had failed to engage properly with patients’ families during internal investigations.

A subsequent inspection by the CQC has identified that, although improvements have been made by the Trust, further action is required.  In particular, better arrangements are required to identify premises which contain ligature risks, risks of falls from heights or risks of patients absconding.  It also found that, because the Trust had not put in place robust governance arrangements to investigate incidents, opportunities to learn and reduce the risk of similar events in future had been missed.

Last month the CQC informed the Trust that: “it must make significant improvements to protect patients from risks posed by some of the mental health and learning disabilities ward environments” and “It must put in place effective governance arrangements to ensure that robust investigation and learning from incidents, including deaths, to reduce future risks to patients.”

The CQC also looked at how the Trust had implemented the legal “Duty of Candour”, (which requires Trusts to notify patients (or their representatives), provide an explanation and apologise when an incident has occurred).   It found variations in the way in which this duty was applied, including one case involving the investigation of a patient’s death, in which the Trust had decided that the Duty of Candour was not applicable.

The Trust did not challenge the warning notice and has since written to the CQC with details of improvements it has made.

It is vital that all Trusts and medical professionals ensure that serious incidents are investigated and learned from, in order to improve the safety of services for future patients.

Patients who have been affected by a serious incident have a legal right to be fully informed.  If the Duty of Candour is consistently adhered to by organisations, it is hoped that this will be a positive first step for patients and their families, who often describe their need for an explanation, apology, and reassurance that lessons have been learned.

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