CQC: NHS Deaths Review — House of Commons, 2016-12-13
Topic: Health
Jeremy Richard Streynsham Hunt (Conservative, Centre-right): With permission, Mr Speaker, I will make a statement. On 12 April, I asked the Care Quality Commission to conduct an investigation into lessons that needed to be learned following the tragic death of Connor Sparrowhawk in 2013 at Southern Health NHS Foundation Trust. I pay tribute to his family, and particularly to his mother, Sara Ryan, for persistently and determinedly 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 will be saved I asked the CQC to look at what happened at Southern Health NHS Foundation Trust and to assess more broadly what lessons there are for the NHS as a whole. Its findings make sobering reading. Among other findings, the report says that families and carers often have a poor experience of mortality investigations; that they are sometimes not treated with kindness, respect and sensitivity; that they can feel that their involvement is tokenistic; and that they often question the independence of the reports The report also says that the NHS does not prioritise learning from deaths and misses countless opportunities to learn and improve as a result, and that 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 those who have recently been in their care. As a result, there is inconsistency. Some NHS trusts get elements of mortality reporting right, but not one gets all the elements right. In particular, the leaders of NHS organisations and 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 potentially avoidable deaths and serious incidents, and to 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 done by Professor Nick Black and Dr Helen Hogan We will require trusts to publish that information quarterly, in accordance with regulations that I will lay before the House, so that 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 be asked to identify a board-level leader as patient safety director to take responsibility for this agenda and ensure that it is prioritised and resourced within their organisation. This person is likely to be the medical director. They will 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 that they genuinely involve families and carers. More broadly, instead of the patchwork approach that we currently have, 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. These 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 be working with the National Quality Board to ensure that much more support is offered to bereaved families. As the report highlights issues around support to families, Health Education England will be asked to review the training for all doctors and nurses with respect to engaging with patients and families after a tragedy and, equally importantly, maintaining their own mental health and resilience in extremely challenging situations As the report identified particular concerns about the treatment of people with learning disabilities, we will take two further actions. 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 disabilities mortality review—LeDeR—programme will provide support to families and local NHS areas to enable reporting and an independent, standardised review of all learning disability deaths of people between the ages of four and 74 We will ensure that there is coverage in all regions by the end of next year and full national roll-out 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 I want to address the issue of 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 be working closely with the CQC, NHS Improvement and senior NHS doctors and nurses to get this right, but I want to make it clear to the House that I will not be setting any target for reducing reported avoidable deaths, and nor do I believe it will be valid to compare numbers between hospitals because the data depend on clinical views that may change or vary. I expect—this might surprise some in the House—to see an increase in the number of reported avoidable deaths. This is more likely to be because hospitals get better at spotting and reporting them 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. For example, the number of people experiencing the four main hospital harms is down by a third since November 2012; MRSA and clostridium difficile rates have halved since 2010; and we have 10,000 more hospital nurses in our wards since the Francis report, and they are now at record numbers There is a new healthcare safety investigations branch 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. There is also a consultation concluding this week 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 collection of information about unexpected deaths, analysis of what was preventable and learning from the results. Only by implementing the report’s recommendations in full will we honour the memory of Connor Sparrowhawk, and I commend the statement to the House.