Change that leads to better lives

NDTi calls for greater accountability in response to the CQC’s report into NHS Deaths

As part of the Expert Advisory Group, at NDTi, we welcome today’s publication of the CQC’s report “Learning, Candour and Accountability”.

The report highlights some significant issues that have been gathered in a particularly tight time frame and gives a greater voice to the experience of families and carers. However, we feel the focus on accountability within the report doesn’t go far enough. Whilst the report acknowledges common issues that are particularly worse for people with Learning Disabilities and Mental Health Problems, the focus still remains on systemic changes. We believe this goes beyond systematic problems. This is more about the attitudes and value judgements of health and social care professionals that feed into the systems. Another framework will not be enough to fix this.

The report is saying that Trusts are not good at identifying people with Learning Disabilities and Mental Health. This is extremely disappointing given all NHS Foundation Trusts reported to Monitor (now part of NHS Improvement) that they were compliant with all six criteria which includes criteria #1 “Does the NHS Foundation Trust have a mechanism in place to identify and flag patients with learning disabilities and protocols that ensure that pathways of care are reasonably adjusted to meet the health needs of these patients?” (Source: DH answer to written parliamentary question by Tom Clarke MP, 7 Jan 2015.)

If the trusts are complying with all of the criteria, why isn’t this reflected in the data that has been provided?

NDTi’s Health Lead, Anna Marriot, commented on the findings saying
“We know from the Confidential Inquiry into premature deaths of people with learning disabilities that many of these premature deaths could be avoided through good quality healthcare. This report shows that trusts are too accepting of poor quality care for vulnerable groups of people. We need to call this what it is - and it is discrimination."

There is a system already in place that could look at making changes. The Learning Disabilities Mortality Review programme (LeDeR) (as mentioned in the report) is meeting many of the concerns raised in the report. However, participating in this review is currently voluntary, in light of the CQC’s findings there is a strong argument that participation should be mandatory for all CCGs and Local Authorities.

Anna Marriot further commented that in her experience there is much to learn from holistic reviews of the lives and deaths of people with learning disabilities adding that
“whilst the report calls for learning, at NDTi, we believe this kind of learning cannot be optional. Making participation in the LeDeR programme mandatory will give clinicians the necessary time to reflect on the care and treatment received by some of their most vulnerable patients and ensure continued learning and improvements”.

Learning candour accountability full report 1

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