Report on preventable avoidable unexpected NHS deaths failure medical care.
Following another report published this week, it is clear that the NHS is still not doing everything in its power in order to combat preventable deaths.
The Care Quality Commission (CQC) has criticised how the NHS deals with patient deaths, both in hospitals and in the community.
It found that practices were often inadequate, leading to limited relative involvement and a lack of communication, frequently leaving questions unanswered as to how and why a death has occurred. This in turn will exacerbate the suffering felt by grieving relatives after the death of a loved one.
The report also highlighted some of the high-profile deaths that were caused by neglect, especially where patients were suffering with mental health conditions or learning disabilities, where some of the deaths were preventable.
However, the CQC stressed that not all deaths were the result of a medical failing or problem with the care received, but those that were had not led to the changes in the NHS that would have been expected.
Health Secretary Jeremy Hunt recognised that the NHS trusts had different ways of dealing with preventable deaths which led to ‘inconsistencies’ and their failure to learn from past experiences had ‘not been prioritised’ enough.
One of these inconsistencies was in how the trusts referred to the deaths; the words ‘preventable’, ‘avoidable’ and ‘unexpected’ were all used, for a number of reasons. The CQC have suggested a standard definition for each of these would greatly improve matters and should encourage a more consistent approach.
Mr Hunt also felt that by making the data on these deaths public, would make the NHS ‘more open on preventable patient deaths’; the trusts would be held more accountable and the public would be able to track the progress of their local hospitals.
Health Education England has pledged to review the training of medical staff on how best to deal with patients and their families following a death.
The Academy of Medical Royal Colleges has added that this knowledge is not new to those in the profession, but has highlighted it and as a result, action must be taken to avoid its repeat.
Professor Dame Sue Bailey, chair of the Academy, said ‘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 lessons from this report.’
But for many of the families, this may be too little, too late. Some families have had to endure months, or even years, of little communication and no adequate answers as to how their relative died and why this was allowed to happen. Reform will clearly be a positive step forward, as it should minimise the amount of families with such questions, but for some, they may never receive the answers that they need.