Care Quality Commission Points to Inadequate Bereavement Inquiries

A newly published report suggests that NHS investigations into patient deaths are inadequate, causing more suffering to bereaved families.

The Care Quality Commission found that relatives have frequently been unreasonably excluded from investigations, or given inadequate responses.

Researchers at the CQC have spent an entire year investigating some of the most high-profile cases of neglect in the NHS.

Jeremy Hunt is expected to force health trusts publish statistics on preventable deaths, as a response to the CQC research.

Perhaps the most prominent example of neglect came in the case of 18-year-old Connor Sparrowhawk.

Sparrowhawk suffered from a learning disability and epilepsy, dying while receiving care at an Oxfordshire treatment centre run by Southern Health NHS Trust.

Speaking to the BBC, his step-father Richard Huggins was disappointed about the lack of progress in the healthcare system.

“For the NHS to be consistently surprised by the data, irrespective of the type of report – whether it’s a specific one on learning disabilities or mental health, or more generally – strikes me as disappointing. Everyone’s unexpected death is as important as anyone else’s, they should all be seen as unacceptable. People with mental ill-health and learning disabilities have additional issues that need to be looked at differently and specifically, otherwise they will continue to die. We need to stop these things happening. It beggars belief to me that it is still so endemic”.

The report concluded that there have been failings in the healthcare system, and the NHS must learn from errors.

“When a loved one dies in care, knowing how and why they died is the very least a family should be able to expect,” it concluded.

Commenting on the issue, the CQC’s Dr George Julian was firm on his opinion that the NHS must improve.

“We must learn from these families. Their trust, honesty and candour are an example to us all. We owe it to them, their loved ones and to ourselves to stop talking about learning lessons, to move beyond writing action plans and to actually make change happen.”

Prof Dame Sue Bailey, chair of the Academy of Medical Royal Colleges, concurred with this verdict.

“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. This is not about blaming individuals, but about the health service learning the lessons from this report.”

The Parliamentary and Health Service Ombudsman upheld 338 complaints into avoidable deaths in 2016, up from 2015 ‘s figure of 306.


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