NHS must ‘accelerate’ learning from deaths improvements

The Care Quality Commission said progress in this area was too slow and that problems in the culture of organisations may be acting as a barrier.

“Cultural change is not easy and will take time. However, the current pace of change is not fast enough”

Ted Baker

New guidance was issued to trusts in the wake of a damning CQC inquiry published in 2016, which identified failures in the way deaths were being investigated and reviewed.

The CQC has started assessing NHS trusts’ implementation of this national guidance on learning from deaths as part of its new well-led inspections. It has today published a report of its findings to date.

The regulator found that awareness of the guidance was high, with some trusts taking action to review policies and establish a more robust investigation process to ensure learning was shared and acted on. However, others were finding it more difficult to implement the changes required.

In the document, Professor Ted Baker, the CQC’s chief inspector of hospitals, said the regulator was “beginning to see the start of progress”, but expressed “concern” that the same issues were persisting in some trusts.

He said involving and engaging with bereaved families and carers was an area with which some trusts were continuing to struggle”.

Professor Baker said he was worried that it was the culture of organisations that was stopping trusts making headway on this agenda.

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“Issues such as fear of engaging with bereaved families, lack of staff training, and concerns about repercussions on professional careers, suggest that problems with the culture of organisations may be holding people back from making the progress needed,” he said.

He called for trusts and the system as a whole to establish an “open and honest culture”, where people felt able to speak up as opposed to one that focused on blame.

“Cultural change is not easy and will take time,” he said. “However, the current pace of change is not fast enough.

“NHS trusts need to use the findings of this report to remind themselves of the key drivers to improve learning from deaths, to build on progress made so far and to accelerate the changes needed,” he added.

The CQC found some “limited” evidence that the guidance was better suited for acute trusts rather than mental health or community services.