We recommend that the report is reviewed by Boards and Governing Bodies across the country.

Transcription

1 briefing February 2016 Mazars reprt: the imprtance f gd quality investigatins December 2015 saw the publicatin f Mazars independent review int 10,296 deaths f peple with a learning disability r mental health prblem in cntact with Suthern Health NHS Fundatin Trust. It is a damning and hard hitting reprt. Althugh fcussed n a mental health/ld prvider there are lessns in the reprt fr everyne in the health sectr prviders f any size and shape and cmmissiners. We recmmend that the reprt is reviewed by Bards and Gverning Bdies acrss the cuntry. The Executive Summary can be fund at pages f what is a reprt running t ver 250 pages. We set ut belw sme f their key findings and learning pints. The reprt starts by setting ut Mazars thinking abut the purpse f reviewing the circumstances f r investigating a death which included: T establish if there is any learning fr the Trust, the wider NHS and its partners arund the circumstances f the death and the care prvided leading up t a death. T learn frm any care and delivery prblems r system failures that need t be addressed t prevent future deaths and imprve services. T identify if there is any untward cncern in the circumstances leading up t a death. T be in a psitin t prvide infrmatin t the Crner, if requested. T be able t wrk with families t understand the full circumstances and answer questins. T have the full detail f events available fr any subsequent cmplaint r legal investigatin. Against that backdrp we learn the fllwing: mazars_review_feb2016 1

2 key findings There was a lack f leadership, fcus and sufficient time spent in the Trust n carefully reprting and investigating unexpected deaths. Despite the Bard being infrmed / warned n a number f ccasins, including by Crners and CCGs, that the quality f SI reprting prcesses and standard f investigatin was inadequate, n effective actin was taken t imprve investigatins. The nly natinal nn statutry guidance in place fr SI Reprting allws Trusts t exercise cnsiderable discretin. There was n effective systematic management and versight f the reprting f deaths and the investigatins that fllw. Timeliness f investigatins was a majr cncern. On average it tk nearly 10 mnths frm an incident t clsing a SIRI. They state categrically that this needs t change. The Trust culd nt demnstrate a cmprehensive, systemic apprach t learning frm deaths as evidenced by actin plans, bard review and fllw up, high quality thematic reviews and resultant service change. The invlvement f families and carers was limited. Despite the Trust having cmprehensive data relating t deaths it failed t use it effectively t understand mrtality and issues relating t deaths. Cmmissiners have a rle in demanding better infrmatin relating t deaths and using it t seek imprvement. There was a high level f attritin frm the level f deaths initially recrded t thse subsequently reprted and investigated. There were missed pprtunities fr learning as a result. When an investigatin did ccur the investigatins and reprts were f a pr quality. Again, this mitigated against learning. Leadership and Bard versight The failure t bring abut sustained imprvement in the identificatin f unexpected death and in the quality and timeliness f reprts int thse deaths is a failure f leadership and gvernance. The lack f leadership, fcus and sufficient time spent n reprting and investigating unexpected deaths was at all levels f the Trust, including the Trust Bard. Due t a lack f strategic fcus relating t mrtality and the relatively small number f deaths in cmparisn t ttal reprted safety incidents this resulted in deaths having little prminence at Bard level. There were several facets t this which included: Failure t cnsistently imprve the quality f investigatins and subsequent reprts. mazars_review_feb2016 2

3 Lack f bard challenge t the systems and prcesses arund investigatin f deaths. Lack f cnsistent crprate fcus n death reflected in bard reprts. Ad hc and inadequate apprach t invlving families and carers. Limited infrmatin presented at bard and subcmmittee level. Lack f attentin t key perfrmance indicatrs indicating cnsiderable delays in cmpleting death investigatins. Management and versight f death investigatins There was a limited amunt f crprate versight at all stages f reprting and investigating deaths. There was lack f crprate challenge abut whether the right level f scrutiny was applied. They had little cnfidence that the Trust recgnised the need fr it t imprve its reprting and investigatins. The rle f cmmissiners There had been insufficiently strng enfrcement r attentin paid by a variety f cmmissiners in requiring imprvement and accepting pr quality investigatins and the cnsiderable delays in receiving reprts. Reprt quality and timeliness There was very pr quality f written investigatins at all stages. At least 30% f reprts were f a pr standard; sme wuld have caused further distress t families due t the carelessness with which they have been written and sme had t be returned by cmmissiners. There was little evidence that there was any effective effrt t imprve the quality f the reprting. The reprts were nt reviewed with any significant challenge r rigur. Timeliness was a majr cncern. Timeliness f reprting t StEIS and getting reprts t clsure panels was particularly weak. 90% f SIRIs were nt cmpleted within 45 days. Learning frm deaths The Trust culd nt demnstrate a cmprehensive, systemic apprach t learning frm deaths as evidenced by actin plans, bard review and fllw up, thematic reviews and resultant service change. Actin plans in SIRIs culd nt always be linked t the evidence in the SIRI reprts and the recmmendatins being made. mazars_review_feb2016 3

4 Actins were nt lgged crprately and similar actins recurred thrughut reprts suggesting that lessns were nt being learnt. High quality, timely investigatins are crucial fr learning, fr families, fr service imprvement, fr cmmissiners and t prvide inquests with accurate infrmatin. These were nt being prduced. Family and carer invlvement 64% f investigatins did nt invlve the family. When cntacted, nly 4% f families declined invlvement. There was a lack f separatin between the clinical team supprting families clinically with bereavement and the lead prfessinal undertaking the investigatin. When there was invlvement, very few cases invlved face t face meetings and cncerns set ut by families were nt addressed. Reprts were ften careless, lacking in attentin t detail with grammar, spelling and date errrs that demnstrate a lack f quality review. There was als a lack f curtesy in naming the deceased. Radically mre effrt needs t be made t develp the right culture acrss the Trust t engage with families when deaths ccur. The Trust must cntinue t ensure systems t mnitr Duty f Candur increase meaningful invlvement, in particular, when unexpected deaths ccur. recmmendatins 23 recmmendatins were directed at the Trust themselves and 9 at cmmissiners. There were als 7 natinal recmmendatins made. These include: Trust Ensure staff at all levels recgnise the need fr timely, high quality investigatin and hw t include families and t ensure learning is demnstrated. The bard r its sub cmmittees shuld receive regular reprts f all incidents f deaths. The bard shuld ensure that natinal and trust plicy/ guidance are being fllwed. A template fr a thematic review shuld be prduced. Separatin f peple respnsible fr quality assurance and thse undertaking investigatins are needed. Quality assurance prcesses shuld include independent review and sign ff. High prfessinal standards shuld be achieved in written presentatin. There shuld be explicit actin t cmmence investigatins prmptly even when a crner s cnclusin is nt immediately available unless there is a specific reasn t delay. All deaths f service users in detentin shuld be investigated, whether expected r nt. mazars_review_feb2016 4

5 Cmmissiners CCGs shuld discuss the implicatins f this review with acute care prviders and agree a prtcl fr ensuring jint investigatin between NHS prviders, particularly fr peple with LD. The CCG shuld take actin t ensure that reprts are prvided t clsure panels within 60 days as required. The CCG shuld take actin t ensure that the quality f investigatins imprves radically. Natinal NHS England shuld highlight learning frm this review fr ther NHS Trusts. NHS England s patient safety team shuld ensure that Mental Health and Learning Disability prviders and Trusts are prvided with fcussed MH / LD case examples r a specific framewrk t infrm their wn clear and transparent lcal plicies fr deciding what deaths t reprt and investigate. NHS England shuld prvide further guidance fr Mental Health Trusts n what shuld be reprted t CQC under Regulatin 16 and t NRLS. what next? Readers might want t start by cmparing their wn rganisatin with the flw charts and RAG ratings n pages f the reprt. These cver decisins t investigate, the investigatin prcess and timescales. There is als a prpsed framewrk fr Bard Assurance n mrtality and unexpected deaths at page 107. Hw wuld yu assess the quality f yur SIRI reprts? Here Mazars reviewed 191 reprts and nly assessed 19 f thse as being gd r excellent! We are wrking with clients n risk identificatin, wnership and management and n hw t cnduct RCA s fllwing a serius incident. Please d nt hesitate t cntact us t discuss yur particular requirements and needs. The fcus n the quality and timeliness f investigatins is grwing. The Independent Patient Safety Investigatin Service (IPSIS) ges live n 1 April 2016 s we can expect the fcus t intensify thrughut Jill Masn Partner T +44(0) Jill.Masn@mills-reeve.cm T +44(0) Mills & Reeve LLP is a limited liability partnership authrised and regulated by the Slicitrs Regulatin Authrity and registered in England and Wales with registered number OC Its registered ffice is at Mnument Place, 24 Mnument Street, Lndn, EC3R 8AJ, which is the Lndn ffice f Mills & Reeve LLP. A list f members may be inspected at any f the LLP's ffices. The term "partner" is used t refer t a member f Mills & Reeve LLP. The cntents f this dcument are cpyright Mills & Reeve LLP. All rights reserved. This dcument cntains general advice and cmments nly and therefre specific legal advice shuld be taken befre reliance is placed upn it in any particular circumstances. Where hyperlinks are prvided t third party websites, Mills & Reeve LLP is nt respnsible fr the cntent f such sites. Mills & Reeve LLP will prcess yur persnal data fr its business and marketing activities fairly and lawfully in accrdance with prfessinal standards and the Data Prtectin Act If yu d nt wish t receive any marketing cmmunicatins frm Mills & Reeve LLP, please cntact Suzannah Armstrng n r suzannah.armstrng@mills-reeve.cm mazars_review_feb2016 5