A national review carried out by the Care Quality Commission (CQC) found that the NHS is missing opportunities to learn from patient deaths and often families are not involved in the process or listened to when an investigation happens.
The review considered how the NHS Trusts identify, report, investigate and learn from deaths and concluded that there is no consistent national framework in place to support the NHS investigate deaths which may be caused by problems with care.
The review was undertaken at the request of the Secretary of State for Health following findings of the NHS England report into deaths of people with learning disability or mental health problems that were cared for by Southern Health England.
The review was based on evidence gathered following visits to 12 NHS Trust and also following discussions with over 100 families and carers.
The review highlighted that the Trusts had failed to consider the families’ perspective. Of the 27 investigation reports reviewed by the CQC across 12 Trusts only 3 could demonstrate that they had taken the families considerations into account.
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 and carers are not always properly involved in the investigations process or treated with the respect they deserve.”
The conclusions reached by the review certainly reflect our own experience of dealing with cases where deaths have occurred.
Delays following Neonatal Death
Kerry Fifield, Partner currently represents a family where their son died shortly after birth. Our client instructed us to investigate the circumstances of her son’s death and the treatment she received in September 2013. A Serious Incident Report and Action Plan by the hospital dated October 12, 2013 concluded that there had been a number of failures. Even though the admissions were made within the report the Trust failed to make any formal admissions in relation to the Clinical Negligence Claim.
The continuous delays by the NHS Trust meant that our client had to obtain an independent report from a Consultant Obstetrician. It took until April 2015 before the NHS Litigation authority, on behalf of the Trust, formally admitted that the death could have been prevented and promised a letter of apology. It then took them another five months for the Trust to send the apology letter.
This is an example of a family’s grief being compounded as a result of delays by the Trust in acknowledging their errors and forcing a family through protracted investigations all of which could have been avoided. At a time when families are emotionally vulnerable Trusts can appear to show little empathy in respect of what the families are going through.
If you are concerned about medical treatment or death of a family member whilst receiving medical care do not hesitate to contact one of our experienced solicitors on 0800 3168892 or click here to contact us online.