Care Quality Commission Review: Deaths in the NHS

Baroness Jolly Excerpts

Tuesday 13th December 2016 Lords Chamber

[Lord Hunt of Kings Heath (Lab)]

My Lords, I thank the Minister for repeating the Statement and take this opportunity to offer my condolences to the noble Lord, Lord Prior, on the death of his father.

The circumstances of Connor Sparrowhawk’s death were shocking and I pay tribute to his family, who fought so hard for justice and to ensure that other families do not have to go through what they did. The findings of this report are a wake-up call: relatives shut out of investigations, reasonable questions going unanswered and grieving families made to feel like a pain in the neck, or that they would be dealt with better at a supermarket checkout. This is totally unacceptable and we therefore strongly welcome the recommendation of a national framework and the specific measures which the Secretary of State has outlined. I assure the Minister that we will work with her and the Care Quality Commission to support the establishment of such a framework in a timely fashion.

Families and patients clearly should not be forgotten in the process. Will the Minister pledge that families and carers will be equal partners in developing the Government’s plan for implementing the CQC’s recommendations? Does she agree that those who work in the NHS show extraordinary compassion, good will and professionalism but also that when something sadly and tragically goes wrong, it can often be the result of a number of interplaying systematic failures? A national framework will therefore provide welcome standards and guidance across the service.

Does the Minister recall that the previous Labour Government set up the National Patient Safety Agency, based on airline experience, which was responsible for monitoring patient safety incidents, including medication and prescribing error reporting? Does she also recall that the agency was scrapped under the Health and Social Care Act 2012 and will she acknowledge that this decision was a mistake? Can the Minister tell me what happened to the national reporting and learning system which the NPSA had developed to do the very work that she has outlined in the Statement today?

I was interested in the Minister’s comments about the Secretary of State not setting any targets for reducing reported avoidable deaths. I understand the reasons—it is a sensible approach—but it is one thing for the Secretary of State to say it and another for the different multilayered sections of bureaucracy to understand it. Can she assure me that the Secretary of State will make it clear to the various regulators that targets are not to be set? Equally, I agree with her point that seeing an increase in the number of reports of potentially avoidable deaths may well be a sign of care getting better rather than worse. But explaining that to the media and the public will be a challenge. Can she tell me that that will be a priority for the Government when these reports are published?

For a national framework and the proposed measures to succeed, investment will be necessary as well. Can the Minister confirm whether hospitals will receive extra funding to carry out the additional requirements that the CQC has recommended? Crucially, will this include safe staffing levels? The House will know that hospitals across England are suffering chronic staff shortages, leaving doctors and nurses overstretched. To go back to the mid-Staffordshire inquiry, Sir Robert Francis called for safe nurse staffing levels to be published by NICE. But when NICE attempted to do that, it was blocked by the Government. Will the Minister now commit to NICE publishing safe staffing levels, as recommended by the Francis report?

We saw reports over the weekend that the bed shortages in England have got so bad that seriously ill patients with eating disorders have to travel to Scotland for treatment. This is leaving some of the most vulnerable in our society hundreds of miles away from their homes. If the Government are interested in safety, does the Minister believe that this practice is safe and sustainable?

In conclusion, the CQC has called for the issues addressed in its report to be a national priority and for all those involved in delivering safe care to review the findings and publish a full report. The Opposition absolutely agree with that. Action is needed. We welcome the recommendations and we stand ready to work with the Government to ensure that these issues are no longer ignored.

[Baroness Jolly (LD)]

My Lords, I, too, thank the Minister for repeating the Statement and echo the condolences offered by the noble Lord, Lord Hunt of Kings Heath. I declare my interests as set out in the register. I am chair of a learning disabilities charity caring for adults across England.

We welcome the findings of this report but are saddened that we should need one. However, we welcome its publication and recommendations and hope that they will be taken forward and acted upon as a matter of urgency.

I am going to talk about families, governance and learning good practice from unexplained death inquiry processes. In the report, the Secretary of State said:

“The lesson of Mid Staffs, Morecambe Bay and indeed other injustices like Hillsborough is that when families speak out we must listen”.

Surely another lesson is that a trust, or even a regulated care setting run by a charity or the private sector, should reach out to the family first after the family member dies in an unexplained way. We recognise that the emphasis in the report on the importance of including and listening to families in investigations is extremely important, but is this not what common decency should require and families expect, and should this not already be happening?

The situation at Southern Health NHS Foundation Trust reflects what is known across the sector: that whether we like it or not, mental health and learning disabilities are always considered after acute and community services. As long as I can remember—and my involvement with the NHS began at the end of the 1990s—commissioners thought of them last and there was certainly nothing approaching parity of esteem. Now, at least for mental health, we have parity of esteem, and we should have processes in place that are as good and as robust as in all other NHS settings. The chair of the trust should work with the CEO to make sure this happens and a named non-executive director on the board should have ownership of the process. Sadly, this situation is nothing new. Trusts have struggled with this for years and it has to be kept on the agenda. I mean this literally as well as figuratively. It should not be relegated to a subcommittee; it should be on a full board meeting agenda by default.

I commend the processes adopted by Mersey Care NHS Foundation Trust. In such circumstances as we have been discovering, it carries out a review within days, very quickly, while all the involved staff are still in post and details are not forgotten—and, of course, families are involved.

Any good unexplained deaths investigation or complaints system should always have an element of learning built into it. This should be shared within the organisation and also within the sector, and there should be a process to make that happen. Processes currently seem to be ad hoc. Standards and definitions should be standardised into a common framework, as indicated by the report.

I have three key questions for the Minister. First, will the Government consider extending the recommendations of this report to regulated residential settings where those with a learning disability or a mental health condition are being cared for? Secondly, the report outlines the need for a national framework. Will the Minister outline who will co-ordinate the work outlined in the report and who might be involved, and indicate its expected completion date? Finally, will the framework contain recommendations about sharing good practice within the organisation and the sector?

[Baroness Chisholm of Owlpen]

My Lords, I thank noble Lords for the questions that have been raised. I particularly thank the noble Lord, Lord Hunt, for mentioning the sad death of my noble friend Lord Prior’s father. It is sad that I should have to be standing here instead of my noble friend on this occasion.

This is indeed a wake-up call. As the noble Lord, Lord Hunt, said, we have all been absolutely shocked by this report. This is a cross-party issue and something that we all need to get involved in, and I very much welcome the noble Lord’s understanding about that.

The noble Lord mentioned families and carers being equal partners, which is indeed absolutely essential to what is being brought forward. When families have a loved one in hospital, it is absolutely essential that they can be sure that if they have a concern, they will be listened to, whoever they go to. When somebody we love goes into hospital, one of the things we all feel is a sense of relief that they are now somewhere where they are going to be looked after, cared for and treated in the best possible way. If we cannot feel that that care is going to continue when we go home at night, having been with them all day, there is something very wrong with our system. We are going to make sure that that happens, and that is exactly why my right honourable friend the Secretary of State said he is determined that all the recommendations in the report will take place.

Several points were made, and I will try and get through some of them. We feel that this is not an issue of funding. Trusts already have investigations, and we will support them and make sure that best practice is followed, particularly in the training of clinical staff and in improving the way in which they investigate safety incidents. This is not about funding; this is about creating a culture where NHS trusts make sure that if somebody comes forward with a concern, they are listened to immediately. One way to help with that is the board level leader who will be put in place—a patient safety director—to take responsibility for this particular agenda. This has already been tried in the Yorkshire and Humberside region, with good feedback. It is looking at deaths and avoidability, and degrees of avoidability, and where lessons can be learned from the deaths, even if they are inevitable.

I hope that with those remarks, the noble Baroness and the noble Lord will realise that this is a wake-up call for us all and that we are going to take forward all the recommendations. It is impossible to have a timeframe for this, but we need to make sure that it is done properly and that robust actions are taken to make sure that what happened earlier on will never happen again.