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Care Quality Commission Review: Deaths in the NHS

Volume 777: debated on Tuesday 13 December 2016


My Lords, with the leave of the House, I shall now repeat a Statement given in the other place by Jeremy Hunt, Secretary of State for the Department of Health. The Statement is as follows:

“On 12 April this year, I asked the CQC to conduct an investigation into lessons that needed to be learned following the tragic death of Connor Sparrowhawk in 2013 at Southern Health NHS Trust. I want to start by paying tribute to his family, particularly his mother, Sara Ryan, for her persistent and determined 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 saved.

I asked the CQC to look at what happened at Southern Health NHS Foundation Trust, but also to assess more broadly what lessons there are for the NHS as a whole. Its findings make sobering reading. Among other findings, the report said that families and carers often have a poor experience of mortality investigations. They are sometimes not treated with kindness, respect and sensitivity. They can feel that their involvement is tokenistic and often question the independence of the reports.

The NHS does not prioritise learning from deaths and misses countless opportunities to learn and improve as a result. 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 who have recently been in their care. As a result, there is inconsistency. Some NHS trusts get some elements of mortality reporting right, but not one gets all elements right. In particular, the leaders of NHS organisations, 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 deaths that were potentially avoidable and serious incidents, and 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 by Professor Nick Black and Dr Helen Hogan.

We will require trusts to publish that information quarterly, in accordance with regulations I will lay before the House, so that local 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 also be asked to identify a board-level leader as patient safety director to take responsibility for this agenda and ensure it is prioritised and resourced in their organisation. This is likely to be the medical director. They will also 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 genuinely involve families and carers. More broadly, instead of the patchwork approach we have currently, 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. Their 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 work with the National Quality Board to ensure that much greater support is offered to bereaved families in the future.

As the report highlighted particular issues around support given to families, Health Education England will be asked to review the training for all doctors and nurses with respect both to engaging with patients and families after a tragedy and, equally importantly, maintaining their own mental health and resilience in extremely challenging situations.

Finally, because the report identified particular concerns about the treatment of people with learning disabilities, we will take two further actions. First, 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 Disability Mortality Review Programme will provide support to both families and local NHS areas to enable reporting and independent, standardised review of all learning disability deaths between the ages of four and 74.

We will ensure that there is coverage in all regions by the end of next year and will reach full national rollout 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. So I want to address 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 work closely with CQC, NHS Improvement and senior NHS doctors and nurses to get this right, but I want to make clear to the House that I will not set any target for reducing reported avoidable deaths. Nor do I believe that it will be valid to compare numbers between hospitals, because the data depend on clinical views which may change or vary. It may surprise the House that I expect to see an increase in the number of reported avoidable deaths. This is likely to be hospitals getting better at spotting and reporting them, rather 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.

The number of people experiencing the four main hospital harms are down by a third since November 2012. MRSA and C. diff rates have halved since 2010. Ten thousand more hospital nurses have been recruited since the Francis report; they are now at record numbers. A new Healthcare Safety Investigation Branch has been set up 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. And this week we conclude consultation 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 collecting of information about unexpected deaths, analysis of what was preventable and learning from the results. Only by implementing its recommendations in full will we honour the memory of Connor Sparrowhawk. I commend this Statement to the House”.

My Lords, that concludes the Statement.

My Lords, I thank the Minister for repeating the Statement and take this opportunity to offer my condolences to the noble Lord, Lord Prior, on the death of his father.

The circumstances of Connor Sparrowhawk’s death were shocking and I pay tribute to his family, who fought so hard for justice and to ensure that other families do not have to go through what they did. The findings of this report are a wake-up call: relatives shut out of investigations, reasonable questions going unanswered and grieving families made to feel like a pain in the neck, or that they would be dealt with better at a supermarket checkout. This is totally unacceptable and we therefore strongly welcome the recommendation of a national framework and the specific measures which the Secretary of State has outlined. I assure the Minister that we will work with her and the Care Quality Commission to support the establishment of such a framework in a timely fashion.

Families and patients clearly should not be forgotten in the process. Will the Minister pledge that families and carers will be equal partners in developing the Government’s plan for implementing the CQC’s recommendations? Does she agree that those who work in the NHS show extraordinary compassion, good will and professionalism but also that when something sadly and tragically goes wrong, it can often be the result of a number of interplaying systematic failures? A national framework will therefore provide welcome standards and guidance across the service.

Does the Minister recall that the previous Labour Government set up the National Patient Safety Agency, based on airline experience, which was responsible for monitoring patient safety incidents, including medication and prescribing error reporting? Does she also recall that the agency was scrapped under the Health and Social Care Act 2012 and will she acknowledge that this decision was a mistake? Can the Minister tell me what happened to the national reporting and learning system which the NPSA had developed to do the very work that she has outlined in the Statement today?

I was interested in the Minister’s comments about the Secretary of State not setting any targets for reducing reported avoidable deaths. I understand the reasons—it is a sensible approach—but it is one thing for the Secretary of State to say it and another for the different multilayered sections of bureaucracy to understand it. Can she assure me that the Secretary of State will make it clear to the various regulators that targets are not to be set? Equally, I agree with her point that seeing an increase in the number of reports of potentially avoidable deaths may well be a sign of care getting better rather than worse. But explaining that to the media and the public will be a challenge. Can she tell me that that will be a priority for the Government when these reports are published?

For a national framework and the proposed measures to succeed, investment will be necessary as well. Can the Minister confirm whether hospitals will receive extra funding to carry out the additional requirements that the CQC has recommended? Crucially, will this include safe staffing levels? The House will know that hospitals across England are suffering chronic staff shortages, leaving doctors and nurses overstretched. To go back to the mid-Staffordshire inquiry, Sir Robert Francis called for safe nurse staffing levels to be published by NICE. But when NICE attempted to do that, it was blocked by the Government. Will the Minister now commit to NICE publishing safe staffing levels, as recommended by the Francis report?

We saw reports over the weekend that the bed shortages in England have got so bad that seriously ill patients with eating disorders have to travel to Scotland for treatment. This is leaving some of the most vulnerable in our society hundreds of miles away from their homes. If the Government are interested in safety, does the Minister believe that this practice is safe and sustainable?

In conclusion, the CQC has called for the issues addressed in its report to be a national priority and for all those involved in delivering safe care to review the findings and publish a full report. The Opposition absolutely agree with that. Action is needed. We welcome the recommendations and we stand ready to work with the Government to ensure that these issues are no longer ignored.

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?

My Lords, I thank noble Lords for the questions that have been raised. I particularly thank the noble Lord, Lord Hunt, for mentioning the sad death of my noble friend Lord Prior’s father. It is sad that I should have to be standing here instead of my noble friend on this occasion.

This is indeed a wake-up call. As the noble Lord, Lord Hunt, said, we have all been absolutely shocked by this report. This is a cross-party issue and something that we all need to get involved in, and I very much welcome the noble Lord’s understanding about that.

The noble Lord mentioned families and carers being equal partners, which is indeed absolutely essential to what is being brought forward. When families have a loved one in hospital, it is absolutely essential that they can be sure that if they have a concern, they will be listened to, whoever they go to. When somebody we love goes into hospital, one of the things we all feel is a sense of relief that they are now somewhere where they are going to be looked after, cared for and treated in the best possible way. If we cannot feel that that care is going to continue when we go home at night, having been with them all day, there is something very wrong with our system. We are going to make sure that that happens, and that is exactly why my right honourable friend the Secretary of State said he is determined that all the recommendations in the report will take place.

Several points were made, and I will try and get through some of them. We feel that this is not an issue of funding. Trusts already have investigations, and we will support them and make sure that best practice is followed, particularly in the training of clinical staff and in improving the way in which they investigate safety incidents. This is not about funding; this is about creating a culture where NHS trusts make sure that if somebody comes forward with a concern, they are listened to immediately. One way to help with that is the board level leader who will be put in place—a patient safety director—to take responsibility for this particular agenda. This has already been tried in the Yorkshire and Humberside region, with good feedback. It is looking at deaths and avoidability, and degrees of avoidability, and where lessons can be learned from the deaths, even if they are inevitable.

I hope that with those remarks, the noble Baroness and the noble Lord will realise that this is a wake-up call for us all and that we are going to take forward all the recommendations. It is impossible to have a timeframe for this, but we need to make sure that it is done properly and that robust actions are taken to make sure that what happened earlier on will never happen again.

My Lords, I, too, commend Dr Ryan—Connor’s mother—for her persistence. The truth is that if we could get this right for people with learning disabilities, we would get it right for everyone else. Could the Minister confirm that the national mortality review for learning disability will now be permanent, just like other national mortality reviews such as the one on maternal deaths, rather than for the original three-year period for which it was established? I should declare an interest, having been involved in the tender process that led to the appointment of the Norah Fry research centre to run the national mortality review.

I remember the noble Baroness mentioning this once before in a debate, and I think I said then that there were absolutely no plans for this review to stop. It will certainly be carrying on. We have to ensure that all investigations for mental health patients are of a much higher quality and genuinely involve all the patients and families. We must remember that so often it is the families that know best what is wrong with the patient and how they need to be treated. It is absolutely essential that all clinicians and healthcare workers listen to what relatives or carers are saying about people with mental health or learning disabilities. They know how those people behave at home and how they need to be looked after in hospital. There has to be a joined-up approach between carers, families, clinicians, nurses and everybody who comes into contact with the patient when they go into hospital.

My Lords, changing culture is very important but culture is about having very good leadership. We need clear and greater leadership in our NHS at both clinical and management level. I am pleased to hear that the Minister has said there is going to be some emphasis in that area. With the change in culture, good data and good information systems need to be in place. I understand that there is a move within the NHS towards more locality data-sharing, rather than putting in place a national framework. Surely a national framework—an information-sharing platform—is the way forward if we are truly to understand what is happening in our NHS.

I thank my noble friend for that question. Yes, national data are important, but we also have to remember that data can vary terrifically from region to region. Of course, collecting data is absolutely vital, and there will be national data, but we also need to ensure that the data are suitable for the particular area from where they have been collected.

My Lords, given the lamentably low involvement in investigations of families and others who loved the person who died, how will their experience be audited and monitored in future? As the Minister rightly said—I declare an interest as chairman of the National Mental Capacity Forum—such families often describe not being listened to during the period of illness prior to death, and then not being listened to around the time of death. Without auditing their experience of their involvement in investigations, there is a danger of it being tokenistic and that nothing will really change in the longer term, even though they have a great deal to offer. Will the Minister commit to involving some of the bereavement groups that might provide support and independent monitoring of people’s experiences, and undertake to catalogue centrally the reasons that emerge from such investigations? Only then will we understand if trends really are occurring across the country that need to be dealt with at national level, rather than allowing things to slip at local level.

The noble Baroness, who is very experienced in these areas, makes an important point. The plan is certainly to publish the information quarterly, in accordance with the regulations that the Secretary of State is going to lay before the House, so that local patients and the public can see whether and where progress is being made. Alongside those data, evidence will be published of learning and action that are happening as a consequence of that information, and the information will be fed back to the NHS Improvement regime at a national level so that the whole of the NHS can learn more rapidly from individual incidents.

My Lords, it is right that this matter be discussed in the House with a very sombre attitude, because it is not to use exaggerated language to say that the report has some shocking elements in it, as the Minister has indicated. The way ahead has been set out, but can the Minister assure us that we have got to the bottom of why people in a caring profession have behaved in such an insensitive way to those who are grieving? That comes as a real surprise to us when it is set out in this stark way.

I thank the noble Lord for his question. We must also recognise that most healthcare professionals in this country are doing a fantastic job. Of course, every such incident is appalling and must be looked into, but when I was a nurse, every nurse, doctor and healthcare professional I came across was doing an incredible job, quite often in very difficult circumstances. The noble Lord is right: we must make sure that doctors and nurses are made aware of how they should conduct themselves. That is why Health Education England will be asked to review the training for all doctors and nurses on engaging with patients and families after a tragedy. Equally important is ensuring that they know how they should treat people who come into hospital with mental health issues or learning disabilities. We will be putting psychiatric assessment teams into A&E departments so that they will be able to triage these patients before they go into hospital and pass on to healthcare professionals further down the line what their needs will be.