‘Quick and thorough’ investigations needed for learning disability deaths

Norman Lamb, the Liberal Democrat Shadow Health Secretary, has welcomed the recommendations set out by the Care Quality Commission (CQC) to improve the processes for investigating and learning lessons from unexpected deaths in the NHS, but warned that progress must be made in ensuring that investigations are conducted in a timely manner. 

In April, the Health Secretary instructed the CQC to review how NHS trusts investigate and learn from patient deaths, following the tragic death of Connor Sparrowhawk, an 18-year-old with autism and learning disabilities who drowned in a bath while receiving care at Southern Health. 

A jury inquest found that neglect and other "serious failings" at the trust contributed to his death. After learning about the tragedy as a minister, Norman Lamb has campaigned closely with Connor's mother, Sara Ryan, who found that she was largely excluded from the investigation into her own son's death.  

This week, the CQC's national review found that the NHS is missing opportunities to learn from patient deaths, and that too many families are not being included or listened to when an investigation happens. It raised significant concerns about the quality of investigation processes led by NHS trusts, and the failure to prioritise learning from these deaths so that action can be taken to prevent similar deaths in future. 

The CQC has called for a new national framework, so that NHS trusts have clarity on the actions required when someone dies in their care.  All NHS trusts will be required to collect a range of information on potentially avoidable deaths, and to consider what lessons need to be learned, on a regular basis. Each trust will be asked to identify a board-level leader as patient safety director to take responsibility for this agenda and ensure that it is prioritised within the organisation. 

Responding to a statement by the Health Secretary Jeremy Hunt in the House of Commons, Mr. Lamb paid tribute to Sara Ryan and highlighted the importance of timely investigations when a patient dies in unexpected circumstances. He said:

"I also pay tribute to Sara Ryan, the mother of Connor Sparrowhawk, who has fought tirelessly for justice for those with learning disabilities. I warn the Secretary of State that I think she will take some convincing that things really will change, given all the resistance she has come up against. I hope he has managed to meet her; if not, would he be willing to meet her, with me, to discuss the plans going forward?

"One key issue not covered in the report or statement is the timeliness of investigations. A report nine months or a year after the incident is often no good at all: the organisation has moved on, and people have forgotten what has happened. I commend Mersey Care, which does a very quick, thorough investigation within 48 hours, when the information is really current and people are still shocked by what has happened. That is how Mersey Care seeks to implement the lessons from every tragedy."

In response, the Health Secretary praised Sara Ryan's campaign to achieve justice for people with learning disabilities, as well as Mr. Lamb's role in the Coalition Government. 

"I want to put on the record that the right hon. Gentleman was a big champion for people with learning disabilities when he was in my ministerial team, in particular over issues such as Winterbourne View, which he brought to my attention and did a huge amount of positive work on.

"I have met Sara Ryan. I spoke to her again yesterday. I repeat what I said in my statement, that without her campaigning we would not now be making the huge changes on a national level that we are. I wholeheartedly agree with the right hon. Gentleman’s other comments."


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