Is the NHS Learning from Deaths?

3 Min Read

Doctor holding patients hand

You may recall the press coverage of the much-delayed cervical cancer diagnosis of our client – and former NHS nurse – Julie O’Connor, and her subsequent untimely death.

Julie’s husband Kevin is continuing her campaign to encourage women to attend for their cervical screening test and to prevent something similar happening at Bristol’s Southmead Hospital, or anywhere else.

Before her death in February this year, Kevin and Julie secured an Independent Review of the care she had received, however the hospital Trust have limited the terms of reference to exclude the misreporting of Julie’s smear in 2014. They have also indicated they will not share the report with Kevin due to implications for their staff.

This example brings into sharp focus the NHS’s ongoing challenges when learning from mistakes.

How far has the NHS come?

In 2000 the then chief medical officer published An Organisation with a Memory. The focus was on learning from failure and an open reporting and learning culture.

In between 2000 and today numerous other official reports have recognised the need for a supportive and open culture in the NHS.

The law has changed to support this goal. In 2015 and the concept of ‘Duty of Candour’ became law for all healthcare organisations. It is a legal duty to be open and honest with patients or their families when something goes wrong.

But how far has the NHS itself come?

In 2017 new, national guidance was published to standardise the approach to learning from deaths in all NHS Trusts providing acute, mental health and community health services.

In its latest report Learning from Deaths, the UK’s NHS watchdog the Care Quality Commission (CQC) has reviewed how Trusts have changed following that guidance.    The headline is that it’s early days – but the pace of change is not fast enough.

There are eight guiding principles which set out what bereaved families and carers can expect. These include:

  1. Being treated as equal partners
  2. Being informed of their rights to raise concerns
  3. Being partners in an investigation as they offer a unique and equally valid source of information and evidence

Unfortunately there was routine evidence this was not happening. The report advises:

‘In some trusts we saw ad hoc engagement with families and carers… More needs to be done to make sure that bereaved families and carers are involved from the start.

‘Inspection staff found that staff can sometimes be fearful of engaging with bereaved families and carers. Reasons for this could be linked to a lack of skills or confidence to contact bereaved families, a fear of adding to families’ distress and grief, a culture of blame and concerns about potential repercussions on their professional career.’

The news wasn’t all bad. They saw some examples of positive engagement with families and carers, where Trusts had clear pathways of contact, an open and transparent approach and showed compassionate communication with families.


The CQC are just starting to roll out the Learning from Deaths guidance, but a first look suggests individual Trust responses vary.

Report authors highlighted a lot of the same issues raised in 2000, and say NHS Trusts need to act now to make a change.

Hopefully North Bristol NHS Trust, which operates Southmead Hospital – the focus of the Independent Review into Julie O’Connor’s death – and others, will embrace the need for an open and learning culture.

A culture which supports staff and treats bereaved families as equal partners in a clear, honest, compassionate and sensitive way.