NHS Trusts are failing to undertake effective and compassionate investigation processes into patient deaths and the failing to prioritise learning from these deaths so that action can be taken to improve care for future patients and their families, according to a report published today by the Care Quality Commission.
The report has reviewed over 100 circumstances where a patient passed away and there were concerns regarding the care provided. The concerns range from clear cases of medical negligence to communication and patient dignity issues. Professor Sir Mike Richards, Chief Inspector of Hospitals at the Care Quality Commission, said:
“We found that too often, opportunities are being missed to learn from deaths so that action can be taken to stop the same mistakes happening again. Families of patients who pass away in these circumstances are entitled to expect the NHS to provide a thorough investigation process with compassion, understanding and a transparency that ensures families are not left uninformed or feeling they have a further battle ahead of them to determine what has happened." Deborah Coles, Director of INQUEST and member of the Expert Advisory Group to the CQC Review, said
: “This report must be a wakeup call and result in concrete action. It ratifies what INQUEST and families have been saying for years. There is a defensive wall surrounding NHS investigations, an unwillingness to allow meaningful family involvement in the process and a refusal to accept accountability for NHS failings in the care of its most vulnerable patients.
“Political will and leadership is now required to drive change to a system which is not fit for purpose. We reiterate that only an independent investigation framework can tackle head-on the dangerous systems and practises which are costing peoples' lives. A clear programme of action for 2017 must follow this report, to which families must be integral."
Why is this so crucial? For mistakes to be avoided in the future, lessons must be learned. This is equally as true in circumstances where patients are harmed as well as those devastating situations where patients have died.
The civil law allows families to pursue a claim on behalf of a family member as well as patients, who survive and bring a claim themselves. In doing so, the financial aspects of a lost loved one can be recovered and critically for those who experience a catastrophic, life changing consequence, a claim ensures future care and treatment are funded for life. This process allows some investigation and obtains answers to certain questions but rightly focuses on the individual patients and families involved. The important aspect for patient protection and improving standards of care, is to return those learnings back into the NHS to benefit future patients and staff.
This blog is based on today's Care Quality Commission report that can be found here - http://www.cqc.org.uk/content/cqc-calls-action-end-missed-opportunities-learn-patient-deaths
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