Any preventable death is a tragedy. The impacts are wide and varied. Families, carers, doctors, nurses and wider healthcare teams can all be affected. Though it is impossible to turn the clock back it is essential that one response to any such event is a thorough and robust review. Since the failings at Southern Health Foundation Trust he CQC has been exploring the processes of review and investigation of patient deaths in the NHS. The output is the publication of a report titled Learning, candour and accountability.
Learning, candour and accountability are three very well-chosen words. They are an excellent summary of the purpose, appropriate attitude and desired outcome for any investigation. Sadly, though not surprisingly, the CQC found great inconsistencies in the triggers, approach and quality of investigations across the NHS. Improvements have to be made.
Preventable deaths are at the high end of holding a review. As such, it is appropriate that such cases are led by senior personnel. In general they will be supported with the investigations and input of potentially numerous healthcare professionals of all levels. We should be expect that the leaders of the investigation will have undertaken dedicated training to be able to facilitate a quality review. What, however, of the skills of more the more junior doctors involved?
How appropriate is it to expect the skills required to conduct a thorough review, to simply grow through experience? It’s more than just the process of reviewing itself. Investigations must also reach appropriate conclusions and ensure learning points are applied to future practice. There can be many pitfalls: confirmation bias; failure to gather information from appropriate sources; blame-focus; protection-focus and failure to effectively share learning to name just a few. Bad habits are as just as likely to embed as good practice when we leave development solely to experience.
With proper input and guidance, however, the principles of learning, candour and accountability can be grown from the earliest stages and throughout a career. Practicing their application to lower scale, more routine, even everyday matters today can pave the way to being able to deal with the tragic, controversial and high-profile investigations when the time comes.
How are you responding to the CQC’s latest report?
The skills associated with conducting an effective review are explored in our Practical Leadership & Management Course for Doctors.
