Patients are dying because of a “defensive wall” over fatal errors in the NHS, a watchdog has said.
Deadly mistakes are repeated because hospitals lack guidance on reviewing deaths and fail to follow the rules, according to “absolutely shocking” findings by the Care Quality Commission.
It found that families were being shut out of investigations that were too often poor quality and failed to uncover the truth. Six in ten of the investigations analysed left important questions unanswered and only one in 14 gave a proper answer to the bereaved families.
Inspectors carried out a nationwide investigation after the death of a teenager under the care of the Southern Health trust, which investigated less than 1 per cent of deaths of patients with mental health problems and learning disabilities.
The family of Connor Sparrowhawk, 18, refused to accept the trust’s assurances after he drowned in a bath having suffered an epileptic seizure at a learning disability unit in Oxford. An inquest found that care failures and neglect contributed to his death.
Professor Sir Mike Richards, chief inspector of hospitals, said: “Opportunities are being missed to learn from deaths so that action can be taken to stop the same mistakes happening . . . There is not a single NHS trust that is getting it completely right. An agreed framework needs to be established that sets out exactly what the NHS should do when someone dies and ensures that families are fully involved.”
Almost 300,000 people a year die in hospitals and care services, yet there is “confusion and inconsistency” about which deaths should trigger an investigation, the report found. A third of hospitals did not know how many patients died soon after leaving their care and staff lacked training in looking into deaths, inspectors found after surveying all hospitals, inspecting 12 and analysing dozens of investigation reports.
Family involvement was “tokenistic” with less than 10 per cent saying they were properly involved, inspectors found. Bereaved parents said that they were seen as a “pain in the neck” and had experienced “more courtesy at the supermarket checkout” than in the NHS.
Professor Dame Sue Bailey, chairwoman of the Academy of Medical Royal Colleges, said: “This landmark review reveals in stark detail what many in healthcare have suspected for a long time. Put simply, we have consistently failed and continue to fail too many of the families of those who die whilst in our care.”
Deborah Coles, director of the contentious death charity Inquest, who advised the commission on the report, said: “There is a defensive wall surrounding NHS investigations, an unwillingness to allow meaningful family involvement and a refusal to accept accountability for NHS failings in the care of its most vulnerable patients.”
Peter Walsh, chief executive of the charity Action Against Medical Accidents, said the “absolutely shocking” report “goes further than any other in exposing the dire quality and inconsistency of many NHS investigations”.
He said that the commission had to take some responsibility, however. “There is a responsibility on the CQC itself and NHS England to be more robust in insisting [that hospitals] conduct investigations,” he said.