13 December 2016

The College response to a CQC review which has found that the NHS is missing opportunities to learn from patient deaths and that too many families are not being listened to

Responding to the CQC report, College President, Dr Suzy Lishman said: 

"The investigation of, and learning from, deaths will be significantly improved by the introduction of a national system of medical examiners, a network of independent doctors who will look into each death to determine whether further investigation is required.

Importantly medical examiners will talk to families, listening to their concerns and answering any questions they may have. Pilot schemes have shown that medical examiners improve the quality of death certification, provide valuable information to relatives and identify trends surrounding death early so that action can be taken to prevent further deaths. They are ideally placed to support trusts to monitor causes of death, identify how future care may be improved and reduce the number of avoidable deaths.

Medical examiners are due to be introduced in 2018; this report, as many before it, demonstrates just how important the role will be to safeguard patients in the future.

Another important tool in learning from deaths and improving future care is the post mortem examination. There is a misconception that post mortems add nothing to information obtained from investigations carried out during life but research has repeatedly shown this not to be true. Unexpected findings following a post mortem examination are common, including many that would have changed the way in which the patient was treated. Hospitals currently request very few post mortems, missing an opportunity to learn from patients' deaths. There should be investment in the post mortem service, with consideration given to establishing a national death investigation service to ensure equitable access in all parts of the country and maximise the opportunities for learning from deaths, both preventable and unavoidable."