Hospital ordered to publish preventable death data after report

The move, announced by health secretary Jeremy Hunt, has been welcomed by the family of a woman whose death triggered a serious untoward incident investigation earlier this year.

Pamela Briggs’ inquest heard how the probe took seven months, was carried out by one of the doctors involved in the former nurse’s care, and did not initially include evidence from a key witness.

The 69-year-old’s sister, Chris Walton, said: “Sweeping under the carpet will no longer be an option and hopefully hospitals will be forced to admit shortcomings and prove they have acted to remedy their failings.”

Mr Hunt announced the changes after the health watchdog Care Quality Commission released a report into the death of Connor Sparrowhawk, in 2013, at Southern Health NHS Trust.

He said the report also assessed ‘broadly what lessons there are for the NHS as a whole’, and said the findings ‘make sobering reading’.

Concern was raised about families and carers having ‘poor’ experiences of investigations and not being treated with kindness, respect and sensitivity, while they can feel their involvement is ‘tokenistic’ and leaves them questioning the independence of reports, it said.

The NHS ‘does not prioritise learning from deaths and misses countless opportunities to learn and improve as a result’, it added, and a lack of framework setting out how trusts can identify, analyse, and learn from deaths means there is an inconsistency.

Mr Hunt said the changes will take effect from March 31 and will also see the Victoria Hospital publishing evidence of learning and action, and feeding the information back at a national level.

“We will ensure that investigations of any deaths that may be the result of problems in case are more thorough and genuinely involve families and carers,” Mr Hunt said.

“From next year we will become the first country in the world to publish data on avoidable deaths at a hospital by hospital level.

“And I want to address the issue of how we ensure data published about avoidable deaths is accurate, fair and meaningful, and ensure that the process of publication rewards openness and honesty.”

On Monday, The Gazette revealed how grandmother Patricia Fowler died after being left in a hospital bed for three days because an admin blunder meant doctors didn’t know she was there.

The hospital said lessons had been learned and apologised to Mrs Fowler’s family, but would not say what specifically had changed to prevent a similar mistake happening again. It also said it would respond to Blackpool coroner Alan Wilson’s concerns about the investigation into Mrs Briggs’ death.

Solicitor Diane Rostron, who is representing Mrs Briggs’ sister, said: “The NHS urgently needs to address the very serious issues raised within this report.

“In order for lessons to be learned, the investigations following unexpected/untoward deaths must be comprehensive and transparent.

“The approach to such investigations should involve a genuine willingness to understand what has happened and what has gone wrong and not be merely a form filling exercise.”

A Blackpool Teaching Hospitals NHS Foundation Trust spokeswoman said: “We welcome the CQC’s report on learning, candour and accountability within Trusts across England. We will work with the recommendations of the report to ensure appropriate actions are implemented throughout the Trust.”