NHS 'must be more open on preventable patient deaths'

Connor Sparrowhawk Image copyright Sara Ryan
Image caption Connor Sparrowhawk's family raised concerns about how his death was investigated

NHS trusts will start revealing details of preventable deaths as part of shake-up in the way they investigate cases.

Health Secretary Jeremy Hunt said there needed to be improvements after a report criticised the way the NHS dealt with patient deaths in England.

The Care Quality Commision said current practices were inadequate and often caused more suffering to families.

Mr Hunt said rules would be published next year setting out how cases should be identified and looked into.

The CQC report said too often grieving relatives were shut out of investigations or left without clear answers.

The regulator looked at the approach taken across the NHS by both hospitals and community providers, but it placed a particular focus on those caring for people with mental health conditions and learning disabilities.

It came off the back of some high-profile cases of neglect, including the deaths of 33-year-old Richard Handley and 18-year-old Connor Sparrowhawk.

Failures in care

Connor, who had a learning disability and epilepsy, died in 2013 while receiving care at an Oxfordshire treatment centre run by Southern Health NHS Trust.

Initially, the trust classified Connor's death as a result of natural causes after he drowned in a bath.

Following campaigns by his family, an independent investigation found his death was entirely preventable, there had been failures in his care and neglect had contributed to it.

Image copyright Richard's family
Image caption Richard Handley died shortly after undergoing surgery

Richard Handley had lifelong problems with constipation, exacerbated by his Down's syndrome and medication.

He died in 2012, days after being admitted to Ipswich Hospital from a supported living unit run by the United Response charity. A review found Richard's health needs were overlooked, confirming his family's fears.

Not all deaths would represent a medical failing or problem with the way the person had been supported during their life, said the CQC.

But Mr Hunt acknowledged there was an "inconsistency" in the way NHS trusts approached the issue of preventable deaths and learning from what had happened was "not prioritised" enough.

He said by publishing data on avoidable deaths from next April, patients and the public would be able to see which hospitals were learning from their mistakes.

In addition, Health Education England is to review its training of medical staff on dealing with patients and families after a tragedy.

Analysis: By Michael Buchanan, social affairs correspondent

The report says part of the problem lies in what type of death should be investigated.

Terms like "preventable", "avoidable" and "unexpected" mean different things to different trusts.

Many people who contributed to the review opposed calling a death either unexpected or avoidable as it lacked scientific clarity.

The CQC say improving the standard definition of each word, in discussion with families, should form part of the work to develop a national framework.

Speaking to the BBC, Connor Sparrowhawk's step-father, Richard Huggins, said: "We need to stop these things happening. It beggars belief to me that it is still so endemic."

Prof Dame Sue Bailey, chair of the Academy of Medical Royal Colleges, added: "This landmark review reveals in stark detail what many in healthcare have suspected for a long time.

"Put simply, we have consistently failed and continue to fail too many of the families of those who die whilst in our care.

"This is not about blaming individuals, but about the health service learning the lessons from this report."

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Stephen Dalton, chief executive of the NHS Confederation, said: "Both national and local bodies in the NHS are committed to working with families and their representatives to improve how it deals with investigations resulting from unexpected deaths.

"In the aftermath of an unexpected death there are often complex legal and organisational responsibilities to address but the priority must be that all families are treated with nothing short of total respect and compassion."

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