Failure to investigate deaths of vulnerable patients

http://www.theguardian.com/society/2015/dec/21/failure-to-investigate-deaths-of-vulnerable-patients

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The reasons that deaths of people with learning disabilities may not be investigated are many (Pressure on Hunt over NHS deaths, 21 December). At one level there may be the fear of trusts and health boards that sheer negligence will be identified, as perhaps highlighted by Monica Clifford’s long battle to find out more about her sister’s death (A family’s fight for answers, 21 December). At another level there is the continuing ignorance and misunderstanding by health service professionals about what having a learning disability means.

During my career as a clinical psychologist in several NHS services for people with learning disabilities I was frequently asked to address “behavioural challenges” of people whose actions were simply their only way of showing they had a physical problem: the man with Down’s syndrome refusing to leave the house, who turned out to have had a heart attack; the woman refusing to eat, who had bronchial pneumonia; the boy with autism severely self-harming, who had a burst appendix.

This “diagnostic overshadowing” will continue for as long as learning disability is seen as a diagnosis in itself, rather than the social label it really is. Until society can change its fundamental belief that people “suffer” from a learning disability, and that therefore death must be a merciful release for the individual and their families, we are unlikely to see a change in how deaths are investigated. I’m afraid I can already hear the tutting in NHS boardrooms at the cost of “unnecessary” investigations.Dr Sally CheseldineEdinburgh

• The failure on the part of Southern Health NHS foundation trust to properly identify those deaths of patients deemed necessary for investigation (Hunt criticises NHS trust’s response to unexpected deaths, 18 December) highlights once again the deficiencies in our system of death certification and registration. Rogue doctors, and by implication organisations, remain able to certify their way out of trouble, untouched by independent scrutiny of their decision and crucial learning opportunities. Coroners too do not all strike the right balance in setting local reporting arrangements: 2014 reporting rates of deaths to coroners in England and Wales ranged from 24% of all deaths to 96%. The coroner cannot know what the coroner does not hear. The government must immediately implement the recommendation of Tom Luce in his fundamental review of death certification and coroner services in England and Wales and Northern Ireland (2003) that all deaths not reported to the coroner should be scrutinised by a medical examiner. Provision has been made in the 2009 Coroners and Justice Act, so why the delay? The proper investigation of death is a service to the living.Dr Maxwell McleanUniversity of Huddersfield

• Regarding the secretary of state’s announcement that the Care Quality Commission will undertake a wider review of how deaths are investigated by trusts, there is already a tried and tested system to investigate deaths ready to be implemented – independent medical examiners.

Inadequate hospital investigations mean families are left without answers and mistakes are not learned from. These problems could be addressed with the introduction of independent medical examiners to scrutinise deaths. Pilot schemes have shown that medical examiners work closely with families and health professionals to answer questions and address concerns, help avoid mistakes and reduce litigation.

Despite medical examiners being recommended by three independent inquiries – Shipman, Mid Staffordshire and Morecambe Bay – their introduction has been persistently delayed.

If we are serious about improving patient safety across the whole of the health and social care system, this valuable new role should be introduced without further delay.Dr Suzy LishmanPresident, Royal College of Pathologists

• The secretary of state for health, Jeremy Hunt, cannot ignore the scandalous failure to properly report and investigate the deaths of some of society’s most vulnerable people in the care of the state. Casework by Inquest on deaths of learning disability and mental health patients shows that this is a systemic problem. It is now beyond debate that the investigation system is defective and not fit for purpose. Bereaved families and the wider public can have no confidence in a system where trusts investigate themselves over deaths that may have been caused or contributed to by failures of their own staff or systems. It is anomalous that investigations into deaths in health and social care settings are less rigorous than those in other forms of detention. Inquest is calling for a new fully independent system for investigating these deaths. A more open and learning culture could help to safeguard lives in the future. However, in the short term, the magnitude of this failure should prompt an urgent overarching national inquiry. Patients and their families deserve nothing less.Deborah Coles and Helen ShawDirectors, Inquest

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