Care Quality Commission Review: Deaths in the NHS — House of Lords, 2016-12-13
Topic: Health
Judith Anne Jolly (Liberal Democrats, Centre to centre-left): My Lords, I, too, thank the Minister for repeating the Statement and echo the condolences offered by the noble Lord, Lord Hunt of Kings Heath. I declare my interests as set out in the register. I am chair of a learning disabilities charity caring for adults across England We welcome the findings of this report but are saddened that we should need one. However, we welcome its publication and recommendations and hope that they will be taken forward and acted upon as a matter of urgency I am going to talk about families, governance and learning good practice from unexplained death inquiry processes. In the report, the Secretary of State said: "The lesson of Mid Staffs, Morecambe Bay and indeed other injustices like Hillsborough is that when families speak out we must listen" Surely another lesson is that a trust, or even a regulated care setting run by a charity or the private sector, should reach out to the family first after the family member dies in an unexplained way. We recognise that the emphasis in the report on the importance of including and listening to families in investigations is extremely important, but is this not what common decency should require and families expect, and should this not already be happening The situation at Southern Health NHS Foundation Trust reflects what is known across the sector: that whether we like it or not, mental health and learning disabilities are always considered after acute and community services. As long as I can remember—and my involvement with the NHS began at the end of the 1990s—commissioners thought of them last and there was certainly nothing approaching parity of esteem. Now, at least for mental health, we have parity of esteem, and we should have processes in place that are as good and as robust as in all other NHS settings. The chair of the trust should work with the CEO to make sure this happens and a named non-executive director on the board should have ownership of the process. Sadly, this situation is nothing new. Trusts have struggled with this for years and it has to be kept on the agenda. I mean this literally as well as figuratively. It should not be relegated to a subcommittee; it should be on a full board meeting agenda by default I commend the processes adopted by Mersey Care NHS Foundation Trust. In such circumstances as we have been discovering, it carries out a review within days, very quickly, while all the involved staff are still in post and details are not forgotten—and, of course, families are involved Any good unexplained deaths investigation or complaints system should always have an element of learning built into it. This should be shared within the organisation and also within the sector, and there should be a process to make that happen. Processes currently seem to be ad hoc. Standards and definitions should be standardised into a common framework, as indicated by the report I have three key questions for the Minister. First, will the Government consider extending the recommendations of this report to regulated residential settings where those with a learning disability or a mental health condition are being cared for? Secondly, the report outlines the need for a national framework. Will the Minister outline who will co-ordinate the work outlined in the report and who might be involved, and indicate its expected completion date? Finally, will the framework contain recommendations about sharing good practice within the organisation and the sector?