The Health Secretary has asked CQC to undertake a review of the way in which NHS Trusts investigate deaths and learn from these investigations. This request was part of the Government’s response to the Mazars report, which was published in December 2015. NHS England commissioned Mazars to review the deaths of people with a learning disability or mental health problem in contact with Southern Health NHS Foundation Trust between April 2011and March 2015. This was in response to public concern following a series of deaths which the Trust had described as ‘expected’ and had not investigated, most notably Connor Sparrowhawk’s death in July 2013.

The government has asked the Care Quality Commission (CQC) to undertake a review “to look at how NHS trusts across the country investigate deaths to find out whether similar problems can be found elsewhere. We will look particularly closely at how trusts investigate and learn from deaths of people using learning disability or mental health services.” (CQC 2016)

Professor Sir Mike Richards, CQC’s Chief Inspector of Hospitals, stated:

“For most, the care provided has prolonged their life, eased their suffering and helped them to die with dignity. However, this is not the case for everybody. Every year thousands of people under the care of NHS trusts die prematurely because their treatment or care has not been as good as it could have been. Healthcare workers might have failed to identify an illness that could have been treated, not provided the advice that might have prevented an illness developing, not made a life-saving intervention with a person who is critically ill or made some other error that contributed to a premature death.”

This #WeNurses discussion aims to explore how we investigate and learn from deaths and will help to inform CQC’s review.  We will be asking some of the following questions:

• Are there incidences where you have seen things done particularly well?

• What would be the one thing you could change about the investigation process?

• How well do you think learning disability is identified across different sectors – mental health / community / acute?

• What do you see as the being the main barriers in being able to carry out investigations?

• What do you think the main issues are in conducting investigations of patients with a learning disability and/or mental health condition?

• How well do you think families are able to be involved in investigations/reviews and what would help to improve experiences of families?

• How well do you think learning from deaths is disseminated through trusts/organisations? Do you have examples of good practice? If not, what would facilitate better sharing of learning?

For this discussion we will be joined by:

Victoria Bleazard, Head of Mental Health Policy, Care Quality Commission 

@VictoriBleazard 

Victoria is responsible for mental health strategy and policy within England’s health and social care regulator (Care Quality Commission), joining in 2015. This involves developing their approach for regulating mental healthcare in England, and overseeing the organisation’s statutory responsibilities to highlight the care of those detained under the Mental Health Act and Deprivation of Liberty Safeguards. She is currently leading a national review into how the NHS investigates – and learns from – the deaths of patients in its care following the Mazars review into Southern Health FT.

Victoria was previously with the membership and provider charity Rethink Mental Illness for seven years, directing their campaigns and communications department. She led campaigns which transformed legislation, funding and public awareness of mental health (including through our ‘Time to Change’ anti-stigma campaign).Victoria also led a national Psychosis Network of providers, and worked with NHS leaders to create incentives for improvements.

Dr George Julian, specialistadviser to CQC’s review of how the NHS investigates – and learns from –the deaths of patients in its care 

@GeorgeJulian

DrGeorge Julian is a freelance knowledge transfer consultant specialising in the application of research into practice. She started her research career looking at educational provision for profoundly disabled children and since then has conducted research in the fields of psychology, special education, early years education and social care. She now works with researchers, policy makers, care providers and sector-led improvement organisations. 

George is an avid user of social media, a regular blogger, an online activist and an advocate for digital engagement with research. George is one of the people behind the Justice for LB campaign and is currently a specialist adviser to CQC’s review of how the NHS investigates – and learns from – the deaths of patients in its care.