Learning from Deaths
12 April 2019
In March 2019 the Care Quality Commission (CQC) released their first review of the Learning from Deaths that they addressed in their December 2016 report Learning, candour and accountability. This deals with the way in which Trusts investigate and learn from the deaths of people in their care and the extent to which families and carers are involved in the investigations process.
The pleasing thing to note is that there has been some very good progress and some Trusts who have rapidly implemented the guidance. They have appreciated that following a death of a patient there can be many people affected including the extended family and the staff involved. A defensive culture assists no-one in these circumstances.
SANDS in their Guide, Saying goodbye to your baby summarise this in the words of a mother.
“There are no words to describe the utter devastation of walking empty armed out of the hospital. Of travelling home with the car seat you bought locked in the boot of the car because you can’t bear to look at it. Of shutting the door to your baby’s beautifully decorated bedroom and not opening it again for months.”
There are no stronger words that express the need to learn.
The Duty of Candour requires that Trusts act with openness in dealing with avoidable clinical incidents. The CQC note that “In particular, involvement and engagement with bereaved families and carers is an area with which some trusts continue to struggle. Issues such as fear of engaging with bereaved families, lack of staff training, and concerns about repercussions on professional careers, suggest that problems with the culture of organisations may be holding people back from making the progress needed.” For Clinical Lawyers if there is evidence of obstacles to openness being maintained by some Trusts this remains very disappointing.
For those Trusts that are improving their approach by putting in place values and behaviours that encourage engagement with families and carers and support for staff; by having clear and consistent leadership and governance by a specific person who is at a reasonably high level in a Trust’s hierarchy; by creating or maintaining a positive, open and learning culture that encourages staff to speak up about safety issues and has a focus on improving the care of patients; by providing staff with the resources, training and support to carry out reviews and investigations; and have positive working relationships with other organisations also providing care for the person who has died, to enable the sharing of information and learning from any investigation, we commend them.
They are the future of improvement in the NHS. They are the Trusts that will see reductions in clinical incidents and avoidable loss. They are the Trusts that will reduce the legal costs associated with clinical negligence as they have a commitment to learning and openness.
Unfortunately they do not represent all Trusts. The Trusts that have not adopted those values will on occasions continue to destroy the lives of their patients and families by both poor care and then subsequent lack of openness in simply explaining what went wrong.
At Curtislaw we act for far too many families who are put through undue stress because the Trust do not, or refuse, to explain what went wrong with the treatment for far too long. Sometimes in the first 12 months or so of a Clinical case only the Trust have the information to confirm whether the care was substandard. If they adopt a defensive approach the additional hurt to families is immeasurable.
We commend the progress but there is far more that can be done.
The simple fact is that a patient never wants to be harmed.
Jerard Knott Head of Clinical Negligence and Catastrophic Injury
See https://www.cqc.org.uk/sites/default/files/20190315-LfD-Driving-Improvement-report-FINAL.pdf https://www.sands.org.uk/support/bereavement-support/saying-goodbye-your-baby
The Clinical Negligence and Catastrophic Injury Team at Curtis Law is led by Jerard Knott, Senior Associate Solicitor, an APIL Accredited Senior Litigator and Clinical Negligence Specialist. It also includes Lynne Ainsworth, a Law Society Accredited Clinical Negligence Panel Member. We are committed to promoting Patient Safety. The team only acts for Claimants and is dedicated to providing a client care centered high level of service, providing the best possible advice and maximising damages. The department acts on a large number of fatal (including representation at Inquests) and high value cases. The department regularly advises on cases with valuation exceeding £1,000,000. We can be contacted on 01254 297130 or MedNeg@curtislaw.co.uk.
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