Learning from Deaths

The preventable death of Connor Sparrowhawk in July 2013, led to a number of investigations and enquiries into practice where he died and a wider independent review of the deaths of people with a learning disability or mental health problem in contact with Southern Health (Mazars 2015).  The majority of people, however,  do receive good and excellent care from the NHS, with staff working tirelessly under increasing pressures to deliver safe, high-quality healthcare, however, some people do experience care that is not at the standard expected.  It is important therefore that when people die in our care, that the NHS reviews practice and works with others to understand what can be learned from the death in order to prevent recurrence where possible. Reviews and investigations are only useful for learning purposes if their findings are shared and acted upon (National Quality Board 2017).

Research has shown that people with learning disability and People with Mental Health problems have greater health care needs than the general population and often suffer unnecessarily with untreated or poorly managed conditions. People suffer with at least 2 or more co-morbidities and die 15-20 years earlier than the general population (Hollins 2014). It is recognised that if you have a learning disability or a mental health problem, you may not seek advice and support for a physical health concern from primary care or that when you do, that this may go unrecognised with the misunderstanding that the presentation is part of the diagnosis of learning disability, also known as diagnostic overshadowing (Mencap 2011). Achieving parity of outcomes for people with learning disability and mental health problems has been outlined within the ‘recognising the importance of physical health in mental health and intellectual disability (Board of Science 2014).

Following guidance from NHS England (Serious Incidents 2015), deaths will be reported as a Serious Incident (SI), where the learning is so great, or the consequences to patients, families and carers, staff or organisation are so significant for the NHS. The Care Quality Commission (CQC) (2016) in their report ‘Learning, Candour and Accountability reviewed the way that NHS Trusts review and investigate deaths in England, this showed that there was limited understanding of deaths and in some organisations, learning from deaths was not being given sufficient priority with valuable opportunities for improvements were being missed. The CQC suggest that there is much more the NHS can do to engage families and carers and recognise their insights and experiences as being vital to our learning.

In line with the National Quality Board guidance on Learning from Deaths, Humber Teaching NHS Foundation Trust has developed a policy working in collaboration with Mazars and a number of NHS Trusts in the North of England.  This policy details how Humber Teaching NHS Foundation Trust (HFT) will identify, report, investigate and learn from a patient’s death.   Humber Teaching NHS Foundation Trust will work closely with families and or carers of patients who have died.

HFT is working closely with other mental health trusts in the north of England supporting the approach to learning from deaths within Humber and across the North of England.

Please read our Mortality Governance: Learning from Deaths policy here