CQC: NHS Deaths Review

Jonathan Ashworth Excerpts

Tuesday 13th December 2016 Commons Chamber

[Jonathan Ashworth (Leicester South) (Lab)]

I thank the Secretary of State for advance sight of his statement, and I thank the CQC for its report.

Any death is a tragedy for families, but when that death could have been prevented, or was the fault of a system that is meant to care for our loved ones, the trauma is all the more difficult to cope with. The circumstances of Connor Sparrowhawk’s death were shocking, and I, like the Secretary of State, pay tribute to his family, who have fought so hard for justice and to ensure other families do not have to go through what they went through. Connor Sparrowhawk’s step-father, Richard, told Radio 5 live:

“When a loved one dies in care, knowing how and why they died is the very least a family should be able to expect”.

We agree.

The findings of the CQC are a wake-up call: relatives shut out of investigations; reasonable questions going unanswered; and grieving families made to feel like a “pain in the neck” or feeling they would be better dealt with at a “supermarket checkout”. This is totally unacceptable—it is shameful and it has to change. We therefore strongly welcome the recommendation of a national framework and the specific measures the Secretary of State has outlined today. I assure him we will work with him and the Care Quality Commission to support the establishment of such a framework in a timely fashion.

Families and patients should not be forgotten in this process. Will the Secretary of State pledge that families and carers will be equal partners in developing the Government’s plans for implementing the CQC’s recommendations? Does he agree that those who work in the NHS show extraordinary compassion, good will and professionalism? Does he accept that when something, sadly and tragically, goes wrong, it can often be the result of a number of interplaying systemic failures and that therefore a national framework will provide welcome standards and guidance across the service?

Does the Secretary of State recall that the National Patient Safety Agency was responsible for monitoring patient safety incidents in the NHS, including medication and prescribing errors, before it was scrapped under the Health and Social Care Act 2012? Will he perhaps acknowledge in retrospect that scrapping that agency was a mistake?

For such a national framework and the Secretary of State’s proposed measures to succeed, investment will be necessary. Will hospitals and trusts receive extra funding to carry out the additional requirements that the CQC has recommended? More generally, hospitals across England are suffering chronic staff shortages, which is leaving doctors and nurses overstretched and struggling to do basic tasks. We all recall that Sir Robert Francis called for safe nurse staffing levels to be published by the National Institute for Health and Care Excellence, but this guidance has been blocked. Will the Secretary of State now consider committing to NICE publishing safe nurse staffing levels, as recommended by the Francis report?

The Secretary of State is aware of the wider pressures on the service. Will he acknowledge that cuts to social care and the failure to provide it with extra investment in the autumn statement two weeks ago are leaving hospitals dangerously overstretched, with patients at risk of harm?

The Secretary of State will also be aware of the pressures on mental health provision. Over the weekend, we saw reports that bed shortages in England are now such that seriously ill patients with eating disorders are having to travel hundreds of miles for treatment. What does he make of this practice, and does he consider it safe and sustainable?

May I ask the Secretary of State about the heart-breaking case of the death of baby Elizabeth Dixon? I know that he has spoken of this in the past. He rightly ordered an investigation, but I understand from the family that 16 months down the line the investigation has not started. Will he provide the House with an update?

The CQC has called for the issues addressed in its report to be a national priority, and for all those involved in delivering safe care to review the findings and publish a full report. We absolutely agree. Action is needed. We welcome the recommendations and stand ready to work with the Government to ensure that these issues are no longer ignored.

[Mr Hunt]

I thank the shadow Health Secretary for the constructive nature of his comments. He is absolutely right in that, because this issue can unite people in all parts of the House. In fairness, these tragedies happen when those on either side of the House are responsible for the NHS, and we all have a responsibility to work to do better than we are doing at the moment.

I particularly agree with the hon. Gentleman that front-line doctors and nurses work incredibly hard, and we need to get away from a blame culture when these tragedies happen. That blame culture is the root cause of why we are not learning as we should from the problems that arise, because people are worried about what will happen to them personally if they speak out. We have seen this with a number of tragedies. Through the national framework, we are trying to move away from a blame culture. Of course people have to be held accountable. If there is gross negligence and people do totally irresponsible things, then there must be no hiding place and proper accountability: that is what families rightly insist on. For the vast majority of the time, however, people are just trying to do their jobs as best they can. As he rightly says, it is often a systemic problem that can be solved with systemic changes. We are now trying to implement the culture of investigation that has worked so successfully in the airline industry and other industries.

I absolutely assure the hon. Gentleman that families and carers will be equal partners as we develop the new national guidance. This area was one of the most shocking things about the CQC report. I am sure that it was a great surprise to many people in the NHS how excluded many families felt. We clearly have to do better in that respect.

The hon. Gentleman talked about the National Patient Safety Agency, and I pay credit to Sir Liam Donaldson, who was chief medical officer under the previous Labour Government and a great champion of patient safety, but we now have different structures in place. The new CQC inspection regime and the healthcare safety investigation branch are giving equal, if not greater, priority to patient safety.

We discuss on many occasions the funding issues that the hon. Gentleman raised, as I think he is acknowledging with his facial expressions. The point I would make, because we have had a good exchange and I do not want to get into the specific politics of NHS funding, is that this is a win-win, because avoidable harm and death is incredibly expensive for the NHS. The time it takes to carry out investigations when things go wrong is utterly exhausting for the doctors, nurses and managers involved, who would much rather be doing front-line care. Preventing these things from happening in future is the best possible way of freeing up time for people on the frontline.

I will take away what the hon. Gentleman said about the Elizabeth Dixon case and find out what is happening with that review.

The real lesson of today is that every family, every doctor and every nurse has a simple aim when a tragedy happens. It is not about money; it is about making sure that lessons are learned openly and transparently so that history does not repeat itself. That is really what this is about, and that is why we will continue our mission to make NHS care the safest and highest quality in the world.