All fatalities in England are to be investigated by the NHS in an attempt to reduce the number of patient deaths linked to poor care

The 54 specialist mental health trusts in England are to start investigating each death in an effort to learn from mistakes. It is said that in future, they should be investigating cases in which the patient may have received poor or unsafe care more fully. This is particularly the case for patients with bipolar disorder or an eating disorder.

The Royal College of Psychiatrists has drawn up the first guidance, which is supported by NHS England. The aim is to end the existing system, whereby trusts will examine smaller or larger numbers of deaths.

Dr Adrian James, registrar at RCP said: “We hope that this will improve care, save lives and reassure friends and family who have lost a loved one that if they have concerns, they will be acted on [by the trust which was providing care].”

This ‘failure’ to look into patient fatalities became an issue first in 2015 when it was revealed that Southern Health Trust had not examined the deaths of nearly 1,000 autistic or patients with learning disabilities.

One case, in particular, highlighted the failures; Connor Sparrowhawk, an autistic teenager with epilepsy died in 2013 as a result of poor care in one of the trust’s facilities. It was reported that the doctor involved had made 39 different errors.

The new system

Under the guidance, written by RCP, any one of four 'red flags' will automatically trigger an in-depth inquiry. This will be carried out by a senior trust doctor who has had no involvement in caring for the patient.

Included in these red flags are relatives or staff who have voiced unease or concern about their family member’s care, and any patient who has either had an eating disorder or has recently experienced psychosis.

Mandatory investigations will also be enforced when a patient has recently received treatment in a psychiatric ward, or if when they died, they had been under the care of a crisis team or home treatment team.

“Each preventable death is a tragedy and we must learn from each one”

Louis Appleby, professor of mental health at Manchester University and the director of the university’s National Confidential Inquiry into Suicide and Safety in Mental Health, has welcomed the move. He said:

“This is about two things: learning from what goes wrong and the public accountability of public services. Families can be hugely frustrated by the repetition of ‘lessons will be learned’ after a tragedy. Here is an attempt, a practical process, to make sure that happens.

“Large studies are one way, but examining individual cases can turn up crucial details - gaps in care that can be put right for the safety of others.”

Barbara Keeley, the Shadow Cabinet Minister for mental health said: “For families of people with mental ill-health, this guidance will provide vital reassurance that the deaths of some of the country’s most vulnerable patients will be investigated and that these heartbreaking cases can be stopped from happening in the future.”

Caroline Dinenage, the Care Minister, said: “Each preventable death is a tragedy and we must learn from each one. This new guidance will equip trusts with the tools to more quickly identify areas of improvement, provide more support for families and implement changes to better care for people with severe mental health conditions.”

If you have been affected by the above, know that it is OK to feel how you feel. Losing a loved one in any circumstance is incredibly painful, but when you believe they were mistreated, it may take more time for you to come to terms with what has happened.

Talking can really help. Read Lucy’s story to learn more about the power of talking.

Read more about common mental health conditions, including those mentioned in this article, on Counselling Directory.

If you are struggling and need to talk, you may benefit from seeking professional support. Simply enter your location in the box below to find a counsellor near you: