CQC has published a report into the way NHS Trusts review, investigate and learn from the deaths of patients with learning disabilities and mental health problems in their care.
They have found that opportunities to learn from patient deaths are being missed – and too many families are not being included or listened to when an investigation takes place.
Families and carers often have a poor experience of investigations and are not consistently treated with kindness, respect and honesty, despite many trusts saying that they value family involvement.
The report highlights the need for learning from deaths to be given greater priority by all those working in health and social care. Without significant change at local and national levels, it argues, opportunities to improve care for future patients will continue to be missed.
While the review found areas of good practice at individual steps in the investigation pathway, no single trust was able to demonstrate good practice across all aspects of identifying, reviewing and investigating deaths and ensuring that learning was put into practice.
With no single framework setting out what should be done to ensure that as much as possible is learned from deaths, individual providers and commissioners have developed a range of systems and processes, and practice varies widely.
Professor Sir Mike Richards, Chief Inspector of Hospitals, said: "Investigations into problems in care prior to a patient's death must improve for the benefit of families and, importantly, people receiving care in the future... This is a system-wide problem, which needs to become a national priority.
Among the report's recommendations, we call for our partners to work with us to develop a national framework, and for improvements in the way bereaved families and carers are involved in investigations.”