Investigating deaths across NHS

mental health, acute and community

settings reviewing and improving
Expert Advisory Group, May 2016

Policy and Strategy Team

Agenda
No

Item

CQC Lead

Timing

Welcome and introductions

(refreshments available)

Mike Richards

1.30pm

Terms of reference

Mike Richards

1.35pm

Progress so far

Victoria Bleazard

1.45pm

Planning CQCs review:

Assessment framework
Provider online survey

2.00pm
Kim Forrester
Richard Haines

Break

3.00pm

Engagement planning

Kate Moody

3.15pm

Aligning with wider national

programmes

Victoria Bleazard

3.45pm

Any other business

Mike Richards

4.15pm

Close

4.30pm

Policy and Strategy Team

Care Quality Commission: Responding to Mazars

report
Following the publication of the Mazars report, the Health Secretary
asked CQC to:
-

Undertake a focused inspection of Southern Healthcare early in the new year,

looking in particular at the Trusts approach to the investigation of deaths. As
part of this inspection, the CQC will assess the Trusts progress in
implementing the action plan required by Monitor and in making the
improvements required during their last inspection (February 2015).

Undertake a wider review into the investigation of deaths in a sample NHS

trusts (acute, mental health and community trusts) in different parts of the
country. As part of this review, CQC will assess whether opportunities for
prevention of death have been missed, for example by late diagnosis of
physical health problems.

Policy and Strategy Team

Proposed approach: reviewing current practice

What improvements are needed in order for NHS trusts to have robust and
effective mechanisms in place to investigate the deaths of patients/service
users, to allow learning to be quickly embedded to improve care within
organisations and for the system as a whole?
Part 1. Review the process that providers follow to identify deaths of people who are in
receipt of care from acute, mental health and community NHS trusts which may offer
learning opportunities for the provider.
An assessment of how Trusts are currently identifying, investigating and learning

from deaths in their care.

Identify the challenges experienced both by families and Trusts.
Showcase examples of good practice.
Make a number of recommendations for improvement. These will outline changes
required from trusts and commissioners, but also from CQC and other national
bodies.
-

We will look at the systems and processes in place for all deaths, with a focus on the
way these may be applied where people have a learning disability or mental health
problems (aligning with Mazars work).
Policy and Strategy Team

What we hope to produce

CQC will:
Publish a national report outlining our findings which assesses whether other Trusts fail to
properly review, investigate and learn from deaths. This will not identify individuals trusts but
will capture common challenges experienced both by families and Trusts.
It will also:
Showcase examples of good practice in reviewing, investigating and learning from
deaths.
Make a number of recommendations for improvement. These will outline changes

required from trusts and commissioners, but also from CQC and other national bodies.
CQC will work closely with NHSI and NHSE to ensure that our findings influence their
development of good practice guidance.

Policy and Strategy Team

Assessment Framework Cycle

What do we already
know about the
situation?

How do we make
sure things
improve?

Improve

Prepare

National intelligence
Stakeholder views

What are the key

issues we will
need to look at?

Project team
identify KLOEs

Report

What has this told

us?

Activities

How will we do
this?

What activities will we use to gather

evidence?

Policy and Strategy Team

What the review will assess

Key Line of Enquiry

How are the deaths of service users identified, reported and the level of
investigation decided?

1. Identification and reporting

How are the deaths of service users identified, reported and the
level of investigation decided?

2. Investigations

Is there evidence that investigations are undertaken properly and

in a way that is likely to identify modifiable risk factors or missed
opportunities for prevention of death?

3. Governance and Learning

Do NHS trust boards have effective governance arrangements to

drive quality and learning from the deaths of patients in receipt of
care?

4. Involvement of families and

carers

Are families and carers meaningfully involved and how do

organisations continuously improve the way in which families and
carers can contribute to learning?

Policy and Strategy Team

What the review will assess

Key Line of Enquiry
1. Identification and report
How are the deaths of service users identified, reported and the level of investigation
decided?
Good practice standards
NHS trusts have an effective system in place to identify the deaths of patients who die
while in receipt of care
NHS trusts should have a clear protocol in place for determining which deaths are
those for which it has the prime responsibility for investigating if an investigation is
required (this might require reaching agreement with primary care services and the
local authority)
NHS trusts agree the level of their investigation using all available information
including modifiable risk factors
NHS trusts have in place an efficient system for screening deaths of people in receipt
of care to determine: i. whether this is a death that might require further investigation;
ii. whether the death is an event that it should take the lead on investigating.

Policy and Strategy Team

Example of prompts

Each key line of enquiry will be supported by prompts to collect evidence against. The
type of evidence will depend on the activity.

For example, during a site visit we may collect the view of a director during interviews
but we would then look at ways to corroborate this by checking records or case notes.

There will be a number of draft prompts under the four key questions
Key Line of Enquiry
1. Identification and report
How are the deaths of service users identified, reported and the level of investigation decided?
Prompts
1. What are the barriers to effective identification and reporting of deaths that require investigation?
2. How do services make sure decision makers have access to the right information to make the
decision and identify if opportunities for preventing death have been missed?
3. What type of monitoring is in place to make sure deaths are being identified and reported or
thematic requirements are identified?
4. What processes and policies are available to staff making the decision to report and investigate a
death?
5. How are people outside the organisation involved in the initial review e.g. commissioners, other
providers, GPs, families and carers?
Policy and Strategy Team

What the review will assess

Key Line of Enquiry
2. Investigations
Is there evidence that investigations are completed properly and identify modifiable risk
factors or missed opportunities for prevention of death?
Good practice standards
NHS trusts have a policy in place and monitoring system to make sure all
investigations are timely, completed to a high standard and opportunities for preventing
death are identified
NHS trusts make sure staff have the right skills and support to carry out investigations
that are people focussed, meet the best available guidance and address any human
rights issues
NHS staff work effectively with others to look at whole system issues and identify root
causes

Policy and Strategy Team

10

What the review will assess

Key Line of Enquiry
3. Governance and Learning
Do NHS trust boards have effective governance arrangements to drive quality and
learning from the deaths of patients in receipt of care?
Good practice standards
NHS trust boards have an effective system wide approach to monitoring and reviewing
all deaths data and improving investigations when deaths offer learning opportunities
NHS trust boards can demonstrate their commitment to an open, transparent and just
culture that encourages people to report, learn and prevent deaths
NHS trusts have a strategy to learn from and improve services as a result of
investigations following death
NHS trusts board assurance framework facilitates learning, both across and beyond
organisations from deaths of people in receipt of care

Policy and Strategy Team

11

What the review will assess

Key Line of Enquiry
4. Family and carer Involvement
How are families and carers meaningfully involved throughout the investigation process
and how do organisations continuously improve the way families and carers can
contribute to learning?
Good practice standards
NHS trusts have processes in place to involve families and carers in the investigation,
and seek to continuously improve the way families and carers contribute to the
learning
Families and carers have a good experience of involvement in investigations and feel
valued throughout the process
The investigation process is person-centred and recognises the different ways families
and carers may need to be supported throughout
NHS trusts make sure Information is shared with families and carers to support
involvement

Policy and Strategy Team

12

How will we do this?

In the next stage of the assessment framework we will
be looking at the how
We have a number of different activities that we can
employ as a regulator so we will look at which will give
us the most evidence, what existing evidence we can
already access and ask for your input on the best way to
deliver these in the time allowed.
This may include a combination of the activities below;

A intelligence
review of national data sets
National
Stakeholder
views
including
CQC intelligence

National intelligence
Focused
work
Stakeholder
views

with families & carers

sent to all NHS trusts

Interviews and focus groups with

different impact groups

Fieldwork carried out with providers

Activities with our Expert Advisory

Group & online communities

National intelligence
Online survey
Stakeholder views

Policy and Strategy Team

13

Questions

? Do you think we have selected the right key questions to

cover the issues we need to look at and gather enough
evidence for the final report?
? Do you think the key questions will work in the three sectors
we have to review (acute, mental health and community)?
? Any other comments?

Policy and Strategy Team

14

Provider Survey
What?
The survey will be sent out to all Acute, Mental Health and Community NHS Trusts.
Trusts will be given 3 weeks to complete and return the survey.
Why?
To provide data which is not currently available to the CQC that will help answer the
project aims.
To provide additional information, data and context for inspectors ahead of site visits.
To further prompt providers to identify current challenges and barriers to effective
investigations.
How?
Feedback is being gathered from several sites across different sectors on the
appropriateness of the questions and the burden of completing the survey.
Other projects outside of the CQC have been considered to avoid duplication.
FAQ sheet will be provided to facilitate the process and any unnecessary excess
workload for the Trusts.

Intelligence
Team
Policy and
Strategy Team

15

Provider Survey
Question

Deaths in the Community

All

Service
Service
users with users
a Mental
with a
Learning
Health
diagnosis Disability
diagnosis

Deaths of Inpatients
All

Service
users
with a
Mental
Health
diagnosis

Service
users
with a
Learning
Disability
diagnosis

The total number of deaths during 2015/16 of people who

had contact with services in the 6 months prior to death
The total number of deaths during 2015/16 of people who
had contact with services in the 6 months prior to death
which were referred to the coroner as unexpected
The number of deaths of service users in 2015/16 reported
as an incident on local risk management and NRLS
The number of deaths of service users in 2015/16 reported
on STEIS
The number of deaths of service users in 2015/16 where an
initial review has been completed
The number of deaths where you were primary care giver
that had a Level 1 Concise internal investigation
The number of deaths where you were primary care giver
that had a Level 2 Comprehensive internal investigation
The number of deaths where you were primary care giver
that had a Level 3 Independent investigation

Intelligence
Team
Policy and
Strategy Team

16

Provider Survey
Question

Deaths in the Community

All

Service
Service
users with a users
Mental
with a
Health
Learning
diagnosis Disability
diagnosis

Deaths of Inpatients
All

Service Service
users
users
with a
with a
Mental Learning
Health Disability
diagnosis diagnosis

For deaths that occurred between 1st April 2015 and 31st
December 2015 and had a level 1 or level 2 investigation;

How many investigations are completed?

What is the average length of time for completion of

the investigation?
How many had family and carer involvement in the
investigation process?

Free Text
Can you describe what works well and any challenges or barriers for your
approach to involving families and carers?
What do you believe are the biggest challenges and risks to robust and
effective investigations that allow learning opportunities when service users
and patients die?
What single change do you think would have the biggest impact on allowing
learning to be embedded that would lead to improvements to care within
organisations and for the system as a whole?

Intelligence
Team
Policy and
Strategy Team

17

Provider Survey
Feedback has been gathered from multiple sources, including:

Various CQC departments

NHS England
NHS Improvement
NHS Trusts
Mazars
Parliamentary and Health Service Ombudsman

From responses so far received, main points have included:

Definition of in contact
Definition of unexpected
Definition of primary care giver
How trusts identify mental health and learning disability diagnoses
Trusts are not always notified of deaths

Intelligence
Team
Policy and
Strategy Team

18

Break

Policy and Strategy Team

19

Transparency and engagement: our approach

Transparency is a key objective of our engagement for this project. We aim to do this by:

Taking a multi-channel approach to engagement, including website, social media

(twitter and online communities), emailed bulletins and face-to-face meetings, as well
as national and other media.

Transparency about discussions and activities relating to the review. We will do this by
providing regular updates on the website, and sharing this through our engagement
channels in a timely way.

Regular engagement and involvement with key stakeholders, and engaging with
families and carers.

Policy and Strategy Team

20

Transparency and engagement: activities to date

Ongoing conversations, since January 2016, with key stakeholders including NHS
Improvement, NHS England and George Julian from the Justice for LB campaign.

Meetings with other interested parties including INQUEST, Mencap and family
representatives of the Transforming Care Assurance Board.

Established an Expert Advisory Group for the review.

Established new groups on the public and provider online communities.

News story about the review published on our website in April 2016, which had good
media coverage.

News of the review was shared at the same time through various channels including:
o

Twitter using the hashtag #CQCDeathsReview

CQCs emailed bulletins.

Email news sent directly to over 20 strategic partners, including community

and voluntary sector partners and systems partners.

Policy and Strategy Team

21

Transparency and engagement: proposed activities

Engage with families and carers this will be conducted as part of our evidence
gathering for the review.

Conversations with stakeholders, including Relatives and Residents Association, Age

UK, Patients Association, and local Healthwatch network.

Engage with the public online community group each week we will be publishing a
new task for them to feedback on, such as asking for their feedback on how we
propose to gather evidence and how we should promote the findings.

Revise and update our news page on the website this will be a live page which will be
updated on a regular basis, and direct people to the public online community for more
information and how to get more involved.

Engage with providers through the provider online community group and other
channels, including working with NHS Confederation and NHS Providers.

Using media and social media channels tweets talking about issues related to how
trusts inspect unexpected deaths will act as qualitative feedback that we can consider
during the review.

Policy and Strategy Team

22

Transparency and engagement: questions

How do you think that we can capitalise on the online community groups?

What channels do you have available that we can use to help talk about the review?
For example, to promote our online community groups.

Which networks should we be prioritising to speak with providers and NHS

professionals?

Any other comments?

Policy and Strategy Team

23

Aligning with wider national programmes

Policy and Strategy Team

24