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CQC investigation uncovers failings in mental health services

The Care Quality Commission (CQC) have looked into how mental health trusts investigate the deaths of people in their care.

Through on-site visits, surveys and talking to families and health professionals, the CQC gathered evidence to check the processes and systems used by the trusts.

The CQC were unable to identify any trust that demonstrated good practice across all aspects of identifying, reviewing and investigating deaths.

Hannah Bottomley, clinical negligence solicitor at PotterReesDolan, said:

I was shocked that people with learning disabilities and mental health problems, perhaps some of the most vulnerable in our society, were being let down by an NHS Trust in such a significant way. I was also surprised that they were unable to find any of the Trusts demonstrated good practice across all aspects of identifying, reviewing and investigating deaths and ensuring that learning is implemented.

I find all of this very worrying as our clients also tend to be some of the most vulnerable and I would hope that any opportunities to learn lessons and ensure best practice for patients and improve patient safety can be taken and that the recommendations by the CQC are put in place to protect all of us.

The investigation found families are not always treated with kindness and respect and are not always listened to.

The CQC also found no clear system in terms of identifying a death and a lack of consistency in recording deaths of patients who have recently been discharged.

Following the investigation, the CQC recommend learning from deaths needs to be a higher priority to avoid missing opportunities to improve care. Also, bereaved relatives must receive an honest and caring response from the care providers.

Overall, they think that more work is needed to ensure the deaths of people with a mental health illness receive the attention they need.