Learning, candour and accountability

Learning, candour and accountability

The Care Quality Commission

The Care Quality Commission (CQC) has concluded its review of the way NHS trusts review and investigate the deaths of patients in England. The report, ‘Learning, candour and accountability’ analyses processes and systems in English NHS trusts (acute, mental health and community trusts) and highlights the fundamentals that need to be in place to learn from problems in care before the death of a patient. The CQC note that people with a mental health problem or learning disability are likely to experience a much earlier death than the general population, so the review focuses closely on how trusts investigate the deaths of people in these population groups.

The CQC concludes that many carers and families do not experience the NHS as being open and transparent and that opportunities are missed to learn across the system from deaths that may have been prevented. The report states that there are “system-wide” problems with current approaches for engaging loved ones including a level of “acceptance and sense of inevitability” when people with a learning disability or mental illness die early.

Families described a poor experience of investigations and told the CQC they were not consistently treated with respect, sensitivity and honesty. The report outlines six recommendations to improve investigating and learning from serious incidents. The emphasis is on engaging families and carers and recommendations include developing a new single framework on learning from death and advising when an independent investigation may be appropriate.

If you would like to find out about our CPD accredited RCA investigations and duty of candour training or how we can help you to get the right systems in place for managing investigations resulting in death, call me on 07872 130637 or email me on [email protected].

Learning, candour and accountability


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