AvMA statement in response to publication of NHS “Learning from Deaths” guidance for trusts and families

Published: 12 Jul 2018

AvMA welcomes the Learning from Deaths guidance published on 11 July 2018 and is grateful to NHS England for involving families bereaved by patient safety failures and organisations who represent them in its formulation.

However, AvMA is very mindful that guidance alone will not address the strategic and cultural issues in the NHS which allow far too many avoidable deaths to occur. Much needed strategic and cultural change will only occur if there is real progress on the following issues:

  • More robust regulation, training and support to ensure that the NHS follows this guidance and complies fully with the Duty of Candour and Serious Incident Framework, and is held to account if it fails to do so
  • The removal of the controversial “safe space” elements in the current draft Health Service Safety Investigations Bill, which would prevent families from being fully involved in investigations into deaths or being able to use findings of fact from investigation reports in a court or tribunal
  • Funding of specialist independent advice and advocacy services to ensure families are fully aware of their rights and options, and empowered to take part in investigations following a death related to NHS care
  • Funding of legal representation for families involved in inquests concerned with NHS care
  • A commission or similar mechanism to resolve long-term unresolved cases and ensure the NHS learns from them

AvMA chief executive Peter Walsh said:

“The guidance is welcome but we have had guidance before. It needs to be made to stick. If the duty of candour was fully complied with it would be half the battle. However, even that is under threat by current proposals to extend the so-called ‘safe space’ prohibition on disclosure of information found by patient safety investigations, or on using findings from investigations to seek accountability or redress. This is entirely at odds with the spirit of the Learning from Deaths work and would destroy trust in NHS investigations. Families need to be equal partners in investigations or inquests into their loved-ones deaths.”