Policy and Strategy Team

A regulator’s perspective: supporting learning and driving improvement in the investigation of deaths

June 2016

Karen Bennett-Wilson, Head of Hospital Inspections (Mental Health) Kim Forrester, Mental Health Act Policy Manager

CQC purpose and role

Our purposeWe make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve

Our roleWe register, monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find, including performance ratings to help people choose care

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Following the publication of the Mazars report, the Health Secretary asked CQC to:

1. Undertake a focused inspection of Southern Healthcare early in the new year, looking in particular at the Trust’s approach to the investigation of deaths. As part of this inspection, the CQC will assess the Trust’s progress in implementing the action plan required by Monitor and in making the improvements required during their last inspection (February 2015).

2. Undertake a wider review into the investigation of deaths in a sample NHS trusts (acute, mental health and community trusts) in different parts of the country. As part of this review, CQC will assess whether opportunities for prevention of death have been missed, for example by late diagnosis of physical health problems

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1. Focussed Inspection of Southern Health NHS Foundation Trust

January 2016 – short notice, focussed inspection of mental health and learning disability services In addition to our review of previous findings and looking at our specific responsibilities (are services safe, duty of candour and areas relevant to our transferred powers from the Health and Safety Executive), SOS asked us to review the trust’s governance arrangements and approach to identifying, reporting, monitoring, investigating and learning from incidents; with a particular focus on deaths, including ward to board assurance

October 2014 - Comprehensive inspection Report published February 2015, identified several breaches of regulations – trust action plan identified how it would meet the requirements

August 2015 - unannounced, focussed inspection at the Ridgeway centre (LD) and forensic services We found the trust had not taken action or addressed the risk posed by environment at Ridgeway centre – trust asked to take immediate action – trust assured us it would take action

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Findings of the focussed inspection

We found that the trust had not put in place robust governance arrangements to investigate incidents. As a result, the trust had missed opportunities to learn from these incidents and to take action to reduce the likelihood of similar events happening in the future.  The trust had not put in place effective arrangements to identify, record or respond to concerns about patient safety raised by patients, their carers, staff or by the CQC. We found examples of this in a number of the trust’s mental health and learning disability services. Where the trust and others, including CQC had identified risks to the delivery of safe care arising from the physical environment, the trust had not ensured that these risks were mitigated in a timely and effective way. The trust had also failed to identify, record or respond effectively to staff who expressed concerns about their competence to carry out their roles.  These key risks, and actions to mitigate them, were not driving the senior management or board agenda.

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How we reviewed the approach to identifying, reporting, monitoring, investigating and learning from incidents incidents/deaths

Reviewed random sample of investigations into 58 deaths between April 2015 and January 2016, 4 other serious incidents and 38 incident reports Quality and detail of the report and initial management assessment varied considerably – in a quarter of the sample we found:

• the accuracy and/or detail of the content of the IMA did not adequately reflect all the relevant details relating to the death/incident in the care plans;

• the review had not been undertaken within the required timescale;• appropriate actions had not been taken; • learning points had not been well identified and/or there had been missed opportunities to

identify learning.

We asked the trust to review four of the competed investigations and asked NHS England to independently investigate one death

In the incident reports we looked at we found a lack of consistency, variable quality and detail and a lack of effective systems for reporting RIDDORs

The trust were not meeting targets reporting SIRIs

Trust failed to take appropriate action and there was a lack of learning from many investigations and incidents

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CQC regulatory and enforcement action

We asked the trust to take immediate action to ensure the safety of patients at Evenlode and Kingsley ward at Melbury Lodge.

We served a warning notice that informed the trust that:it must make significant improvements to protect patients from risks posed by some of the mental health and learning disabilities ward environmentsit must put in place effective governance arrangements to ensure robust investigation and learning from incidents, including deaths, to reduce future risks to patients

We required the trust to provide CQC with a report, by 13 April 2016, setting out the actions it will take to become compliant with Regulation 17 (2) (a) (b). Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 imposes a legal duty on the trust to ensure good governance.

Ongoing monitoring, working with the trust, will return to the trust shortly (unannounced visit) – still reviewing evidence may take additional enforcement action and working in partnership with others re additional action

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Update on the CQC review of how NHS trusts identify, report, investigate and learn from deaths of people using their services

• CQC is undertaking a thematic review looking at how NHS acute, community healthcare and mental health trusts investigate deaths and learn from their investigations.

• This follows a request from the Secretary of State for Health, which was part of the Government’s response to a report into the deaths of people with a learning disability or mental health problem in contact with Southern Health NHS Foundation Trust. The Secretary of State asked us to look at how all NHS trusts across the country investigate deaths to find out whether similar problems can be found elsewhere.

• As part of the review we are assessing whether opportunities to prevent deaths have been missed. We are also looking particularly closely at how trusts investigate and learn from deaths of people using learning disability or mental health services.

 

CQC Review: Key messages

• The review will involve visits to a sample of acute, community healthcare and mental health NHS trusts, a national survey of all NHS providers, and evidence gathered from families, campaigners, charities and other organisations.

• The review will not involve investigation into specific cases, but we are involving families and will be inviting their comments and discussion through our public online community.

• We aim to identify the specific challenges faced by trusts and develop recommendations for improvement. This is to make sure that when someone receiving services from an NHS provider dies, their death is reviewed and that the provider and others learn from the mistakes made. We will also  use the findings to improve the way we monitor and regulate services.

 • We expect to report on the findings of the review towards the end of the year.

CQC Review: Key messages

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Proposed approach: reviewing current practice What improvements are needed in order for NHS trusts to have robust and effective mechanisms in place to investigate the deaths of patients/service users, to allow learning to be quickly embedded to improve care within organisations and for the system as a whole?

Part 1. Review the process that providers follow to identify deaths of people who are in receipt of care from acute, mental health and community NHS trusts which may offer learning opportunities for the provider.

• An assessment of how Trusts are currently identifying, investigating and learning from deaths in their care.

• Identify the challenges experienced – both by families and Trusts.• Showcase examples of good practice.• Make a number of recommendations for improvement. These will outline changes

required from trusts and commissioners, but also from CQC and other national bodies.

- We will look at the systems and processes in place for all deaths, with a focus on the way these may be applied where people have a learning disability or mental health problems (aligning with Mazars work).

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What we will produce

CQC will:

Publish a national report outlining our findings which assesses whether other Trusts “fail to properly review, investigate and learn” from deaths. This propose that we do not identify individuals trusts, but will capture common challenges experienced – both by families and Trusts.

It will also:• Showcase examples of good practice in reviewing, investigating and learning from

deaths.

• Make a number of recommendations for improvement. These will outline changes required from trusts and commissioners, but also from CQC and other national bodies.

CQC will work closely with NHS Improvement (including HSIB) and NHS England to ensure that our findings influence their development of good practice guidance.

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What the review will assess

Key Line of Enquiry How are the deaths of service users identified, reported and the level of investigation decided?

1. Identification and reporting How are the deaths of service users identified, reported and the level of review or investigation decided?

2. Reviews and investigations Is there evidence that reviews and investigations are undertaken properly and in a way that is likely to identify modifiable risk factors or missed opportunities for prevention of death and improving services?   

3. Governance and Learning Do NHS trust boards have effective governance arrangements to drive quality and learning from the deaths of patients in receipt of care?

4. Involvement of families and carers

How are families and carers treated, are they meaningfully involved and how do organisations learn from their experiences?

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How will we do this?

National intelligenceStakeholder views

A review of national data sets including CQC intelligence

National intelligenceStakeholder viewsOnline survey sent to all NHS trusts

Fieldwork carried out with providers

National intelligenceStakeholder views

Interviews and focus groups with different impact groups

Activities with our Expert Advisory Group & online communities

Focused work with families & carers

We have a number of different activities that we can employ as a regulator so we will look at which will give us the most evidence, what existing evidence we can already access and ask for input on the best way to deliver these in the time allowed.

This may include a combination of the activities below;

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What should be reported to CQC?

Care Quality Commission (Registration) Regulations 2009: Regulation 16

The intention of this regulation is to ensure that CQC is notified of the deaths of people who use services so that where needed, CQC can take follow-up action. This may include inspecting the service or considering whether we need to pursue criminal actions using our transferred powers from the Health and Safety Executive.

Notifications include those deaths that:

• occurred while services were being provided in the carrying on of a regulated activity

Or

• have, or may have, resulted from the carrying on of a regulated activity

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What should be reported to CQC?

• All notifications about deaths must be sent to CQC without delay. We ask that direct notifications are completed within three working days of the death

• All providers must send their notifications directly to CQC unless the provider is has notified the NRLS of the death or the person who died was detained under the Mental Health Act at the time of their death

• Information on what needs to be reported and forms for this can be found on the CQC website

• If you are unclear about whether a particular death needs to be reported you should contact your local inspector to discuss this further

• We will be issuing updated guidance on what needs to be reported to CQC later in the year, this will provide more information but will NOT change the existing requirements which are set out in the Regulations of the Health and Social Care Act

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www.cqc.org.ukenquiries@cqc.org.uk@CareQualityComm

Email the project team: deathsreview@cqc.org.uk

Join the online community: http://www.cqc.org.uk/organisations-we-regulate/get-involved/join-our-online-communities-providers

Twitter updates: #CQCDeathsReview

Thank you