13th December 2016

The CQC’s report – “Learning, candour and accountability: a review of the way NHS trusts review and investigate the deaths of patients in England” – has found:

  • The NHS is missing opportunities to learn from patient deaths
  • A radical change in culture and approach from all parts of the system is needed
  • Significant concerns over the quality of investigation processes led by trusts
  • Too many families are not being included or listened to when an investigation happens.

This is not news to INQUEST or the hundreds of families we’ve campaigned with over the years, whose relatives died whilst under the care of the NHS, particularly those with learning disabilities and mental ill health. Read our report following the Family Listening Day we organised for the CQC, to hear firsthand the family voices and experiences.

Deborah Coles, Director of INQUEST says:
“This report is long awaited recognition of the disgraceful, yet prevalent culture of denial and secrecy so brutally experienced by the relatives of those who have died. From the notification of death, through internal investigations, inquests and beyond, relatives have had to fight every step of the way for the truth.

Political will and leadership are now required to drive radical change to a system which is not fit for purpose. We reiterate that only an independent investigative framework can tackle head-on the dangerous systems and practises which are costing people’s lives. This report must be a catalyst for change, to which families are central; with the necessary parliamentary scrutiny and oversight”.

It is important to note that this review would never have been called, had it not been for the determination of so many bereaved families, who have campaigned tirelessly for open and honest investigations and for change to prevent further needless loss of life.  Most recently, Connor Sparrowhawk’s family in response to the 18-year old’s preventable death under the care of Southern Health in 2013".

Connor’s mother, Sara Ryan said in response to the report:
“There is no learning, no candour and no accountability. This report underplays the impoverished treatment which learning disabled and mental health patients receive in the NHS, in life and in death".

Other families we work with have given their response to the report findings:

Richard Evans, whose daughter Hannah died whilst in the care of an NHS trust, said:
“As a bereaved family we have worked tirelessly over the last 23 months to gain answers, but what about families who cannot summon the motivation or access support in such devastating circumstances? The first draft of the Trust’s investigation was unsatisfactory, however following the resolve from the family the fourth version was acceptable. Incredibly some evidence was only revealed later at the inquest despite an apparently “rigorous investigation and analysis carried out by the Trust into the root cause of the death.

It is simply bewildering that the Trust repeatedly obscured facts surrounding our daughter’s death. In an era of openness and candour, why did the leadership maintain such a stance and not disclose failures at the outset?  This tragedy was plainly preventable, yet nearly two years on the Trust remain ignorant of some of the failings and continue to sacrifice patient safety”.

Sheila Handley, whose son Richard died whilst in the care of an NHS trust, said:
“The position is stark. The report makes clear that at the moment there is no national mechanism under which the premature and preventable deaths of learning disabled and mental health patients are investigated. Money is wasted on poor quality investigations, families are not involved and findings are not shared across the land. As a result, the deaths continue because actions are not taken to prevent repeats.

When my son died, aged 33 years, I just wanted to be able to stop it happening to other families. My voice was not heard.  I hope that this report will be acted upon and measures introduced to kick start change so that a system in which “lessons being learned” can have some meaning. I want the avoidable deaths to stop”.


Notes to editors:

For further information or to arrange interviews with INQUEST and families, please contact Gill Goodby on 0207 263 1111.

A copy of the full CQC report can be found at www.cqc.org.uk

You can view a copy of INQUEST’s formal submission to the CQC review here   

You can view a copy of the full INQUEST family listening report referenced in the release here.

INQUEST’s report: Deaths in Mental Health Detention: An investigation framework fit for purpose? (Feb 2015) can be found here.

To read our media release (Aug 2016) on undisclosed mental health deaths in NHS trusts, click here

INQUEST provides specialist advice on deaths in custody or detention or involving state failures in England and Wales. This includes a death in prison, in police custody or following police contact, in immigration detention or psychiatric care. INQUEST's policy and parliamentary work is informed by its casework and we work to ensure that the collective experiences of bereaved people underpin that work. Its overall aim is to secure an investigative process that treats bereaved families with dignity and respect; ensures accountability and disseminates the lessons learned from the investigation process in order to prevent further deaths.

Please refer to INQUEST the organisation in capital letters to distinguish it from the legal hearing.