CQC Consulting on Assessment Framework Relating to Learning From Deaths

The CQC is reviewing the way it assesses care providers’ approach to learning from deaths in the NHS and social care sectors.  By 2018 new assessments will apply to NHS Trusts, GPs, social care providers and independent services.

In December they published their interim report Learning, candour and accountability, which looked at how NHS trusts review, investigate and learn from deaths.  They found that:

  • families and carers often have a poor experience of investigations and are not always treated with respect, sensitivity and honesty.
  • there’s no single framework for NHS trusts that sets out what they need to do to learn from deaths that may be the result of a problem in care.
  • none of the trusts looked at could demonstrate good practice across all aspects of identifying, reviewing and learning from deaths.

Recommendations in the report included reviewing and strengthening the way the CQC looks at how providers identify and investigate the deaths of patients, the quality of investigations, and how providers learn from deaths and the action they take.

The CQC has been working on how they can put this into practice through the inspection regime and these proposals are now being consulted on.

The questions the CQC are planning to ask care providers are similar to the ones used when gathering evidence for reports:

  • How do you involve families and carers?
  • How do you identify which cases to review?
  • What process do you use to investigate deaths?
  • How do you invest in training and support for deaths investigations?
  • What governance arrangements do you have to make sure you learn from deaths to improve the care you provide?

There are three main parts to the approach the CQC is proposing:

  1. Monitoring and relationship management. Finding out what families and carers are saying by using sources like local Healthwatch, PHSO investigation findings, Patient Liaison Services (PALS), Clinical Commissioning Groups, Bereavement Services and NHS trust meetings. Gathering information that NHS trusts are now required to collect on the numbers of deaths of patients, those that have been reviewed thoroughly and estimates of how many deaths were judged more likely than not to have been due to problems in care.
  2. Risk-based reviews of investigations of individual deaths. Where there are concerns – either raised by families or carers, or from other information – the CQC will review a sample of up to four cases of deaths that have been investigated, selected randomly by the inspection team. These will include a person with a learning disability and person with a mental health need, where these can be identified.
  3. Inspection interviews. They will look at trust policies and procedures. Interviewing the board member and executive who leads on learning from deaths, the operational lead on quality and safety and some of those who investigate cases.

The results will contribute to the ‘well-led’ part of the assessment and rating.

The CQC is keen to hear from families and carers, but are also interested in the views of health professionals.

You can take part by completing the CQC’s online survey.

The survey closes at 6pm on 14 July.

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