Care Quality Commission Review: Deaths in the NHS — House of Lords, 2016-12-13
Topic: Health
Caroline Chisholm (Conservative, Centre-right): My Lords, with the leave of the House, I shall now repeat a Statement given in the other place by Jeremy Hunt, Secretary of State for the Department of Health. The Statement is as follows: "On 12 April this year, I asked the CQC to conduct an investigation into lessons that needed to be learned following the tragic death of Connor Sparrowhawk in 2013 at Southern Health NHS Trust. I want to start by paying tribute to his family, particularly his mother, Sara Ryan, for her persistent and determined campaigning for a proper investigation into what happened. The lesson of Mid Staffs, Morecambe Bay and, indeed, other injustices such as Hillsborough is that when families speak out we must listen. In this case, thanks to Dr Ryan’s efforts, many improvements will be made to the care of people with learning disabilities and many lives saved I asked the CQC to look at what happened at Southern Health NHS Foundation Trust, but also to assess more broadly what lessons there are for the NHS as a whole. Its findings make sobering reading. Among other findings, the report said that families and carers often have a poor experience of mortality investigations. They are sometimes not treated with kindness, respect and sensitivity. They can feel that their involvement is tokenistic and often question the independence of the reports The NHS does not prioritise learning from deaths and misses countless opportunities to learn and improve as a result. There is no single framework that sets out how local NHS organisations should identify, analyse and learn from deaths of patients in their care, or who have recently been in their care. As a result, there is inconsistency. Some NHS trusts get some elements of mortality reporting right, but not one gets all elements right. In particular, the leaders of NHS organisations, their doctors, nurses and other staff simply do not have access to the full picture of how many patients die in their care, which deaths were preventable and what needs to be learned I thank Professor Sir Mike Richards and his CQC colleagues for an extremely thoughtful and thorough report. I am accepting all their recommendations. From 31 March next year the boards of all NHS trusts and foundation trusts will be required to collect a range of specified information on deaths that were potentially avoidable and serious incidents, and consider what lessons need to be learned, on a regular basis. This will include estimates of how many deaths could have been prevented in their own organisation and an assessment of why this might vary positively or negatively from the national average, based on methodology adapted by the Royal College of Physicians from work by Professor Nick Black and Dr Helen Hogan We will require trusts to publish that information quarterly, in accordance with regulations I will lay before the House, so that local patients and the public can see whether and where progress is being made. Alongside those data, trusts will publish evidence of learning and action that is happening as a consequence of that information. They will feed the information back to NHS Improvement at a national level so that the whole NHS can learn more rapidly from individual incidents All trusts will also be asked to identify a board-level leader as patient safety director to take responsibility for this agenda and ensure it is prioritised and resourced in their organisation. This is likely to be the medical director. They will also be asked to appoint a non-executive director to take oversight of progress We will ensure that investigations of any deaths that may be the result of problems in care are more thorough and genuinely involve families and carers. More broadly, instead of the patchwork approach we have currently, all trusts will be asked to follow a standardised national framework for identifying potentially avoidable deaths, reviewing the care provided and learning from mistakes I have asked the NHS National Quality Board, which includes senior clinicians from all national NHS organisations, to draw up guidance on reviewing and learning from the care provided to people who die, in consultation with Keith Conradi, the new chief investigator of healthcare safety. Their guidelines will be published before the end of March next year for implementation by all trusts in the year starting next April. We will also work with the National Quality Board to ensure that much greater support is offered to bereaved families in the future As the report highlighted particular issues around support given to families, Health Education England will be asked to review the training for all doctors and nurses with respect both to engaging with patients and families after a tragedy and, equally importantly, maintaining their own mental health and resilience in extremely challenging situations Finally, because the report identified particular concerns about the treatment of people with learning disabilities, we will take two further actions. First, in acute trusts, we will ask for particular priority to be given to identifying patients with a mental health problem or a learning disability to make sure that their care responds to their particular needs and that particular trouble is taken over any mortality investigations to ensure that wrong assumptions are not made about the inevitability of death. We will also ensure that the NHS reviews and learns from all deaths of people with learning disabilities in all settings. The Learning Disability Mortality Review Programme will provide support to both families and local NHS areas to enable reporting and independent, standardised review of all learning disability deaths between the ages of four and 74 We will ensure that there is coverage in all regions by the end of next year and will reach full national rollout by 2019. As the programme develops, all learnings will be transferred to the national avoidable mortality programme. I have today asked the LeDeR programme to provide annual reports to the Department of Health on its findings and how best to take forward the learnings across the NHS. From next year, we will become the first country in the world to publish data on avoidable deaths at a hospital-by-hospital level. So I want to address how we ensure that data published about avoidable deaths are accurate, fair and meaningful and that the process of publication rewards openness and honesty. Of course, we will work closely with CQC, NHS Improvement and senior NHS doctors and nurses to get this right, but I want to make clear to the House that I will not set any target for reducing reported avoidable deaths. Nor do I believe that it will be valid to compare numbers between hospitals, because the data depend on clinical views which may change or vary. It may surprise the House that I expect to see an increase in the number of reported avoidable deaths. This is likely to be hospitals getting better at spotting and reporting them, rather than because care is deteriorating We should also remember that when there is a tragedy in the NHS, there is always a second victim; namely, the doctor or nurse involved, who invariably suffers huge anguish. So let us today also give credit to all NHS front-line staff for the changes that are already taking place to improve patient safety The number of people experiencing the four main hospital harms are down by a third since November 2012. MRSA and C. diff rates have halved since 2010. Ten thousand more hospital nurses have been recruited since the Francis report; they are now at record numbers. A new Healthcare Safety Investigation Branch has been set up to perform speedy, no-blame inquiries into avoidable harm and death, modelled on the successful system that has operated in the airline industry for many years. And this week we conclude consultation on legislation to create a "safe space" for NHS staff to talk openly about how to improve the safety of care for patients without having to worry about litigation or professional consequences The culture of the NHS is changing following a number of tragedies, but this report shows that there is much progress to be made in the collecting of information about unexpected deaths, analysis of what was preventable and learning from the results. Only by implementing its recommendations in full will we honour the memory of Connor Sparrowhawk. I commend this Statement to the House" My Lords, that concludes the Statement.