News: Learning, candour and accountability – CQC releases report over learning from deaths while in the NHS

The Care Quality Commission today (13th December, 2016) has released their report Learning, candour and accountability  which includes their recommendations, into learning from deaths while in the NHS on Tuesday.

Sir Mike Richards, the CQC’s chief inspector of hospitals, said: “The extent of the problems is more than I expected. The whole system [of investigating deaths] needs an overhaul at national level and local level.” He added that “there is not a single NHS trust that is getting it completely right currently”.(HSJ Dec 2016).

“Learning from deaths needs much greater priority across the health and social care system. Without this, opportunities to improve care for future patients will continue to be missed…. Healthcare providers should have a consistent approach to identifying and reporting, investigating and learning from the deaths of people using their services, and when appropriate, sharing this information with other services involved in a patient’s care before their death… Bereaved relatives and carers must always be treated as equal partners and receive an honest and caring response from health and social care providers. … Reviews and investigations need to be carried out to a high quality, with a focus on system analysis rather than individual errors.” Care Quality Commission Dec 2016

CarolynMy thoughts: Having lived through being a bereaved parent in the NHS complaints system, I know acutely how harrowing the process can be and how not treating loved ones with empathy, compassion and respect, not only compromises majorly investigations based on the truth and real lessons learnt, but also does nothing to prevent prolonged psychological harm as now stated in the statutory Duty of Candour. Something I know in a very real sense. 

It’s why I believe so passionately in supporting and empowering staff to work in a way that not only improves their practice, but improves the experience of bereaved loved ones and also improves the quality of the information gathered by hospital Trusts in their learning.

Jeremy Hunt’s response to the report: 

A journey through NHS complaints using empathy: is proving to be a powerful learning tool with comments form Complaints Managers and Serious Incident Investigators as:

“It was truly the best course I have ever been on and it had a deep impact on me and the way I view things”

“Very brave and open account of journey through NHS complaints which was very moving and very helpful”

“I hung onto every word as it was relevant, important and well presented. The points touched upon will help me as I support individuals and families to obtain answers to questions regarding care and treatment of their loved ones.”

Join me on one of my next two regional days:

26th January 2017 Milton Keynes

21st March 2017 Milton Keynes

OR I will come and work with your team in your organisation. 

Email me on



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