Mersey Care statement on CQC report 'Learning, candour and accountability'

A Mersey Care NHS Foundation Trust spokesman said: “Mersey Care shares the concern expressed in a national review by the Care Quality Commission (CQC) Report that claims the NHS is missing opportunities to learn from patient deaths.


“The report, published today, also highlights that many families are not included or listened to during investigations and calls for a national framework to support the NHS investigate deaths after Sir Mike Richards, chief inspector of hospitals at the CQC, said ‘there is not a single NHS trust that is getting it right currently.’


“Mersey Care recognises there is a lot more that can be done but we are building on a strong track record of patient engagement. We would welcome a national framework for investigations and take the points raised and recommendations extremely seriously from the Mazars Mortality Review into the deaths of people with a learning disability or mental health problem who were being cared for by Southern Health NHS Foundation Trust.


“Since the publication of the Mazars Review last year, Mersey Care has implemented several changes to our practices, including:


  • Reviews of deaths of all patients who have a Learning Disability are undertaken and discussed with the Clinical Commissioning Group, our commissioners
  • A Mortality Review Group has been established in accordance with national guidance and a has a lead Executive Director to oversee actions taken
  • Mersey Care is part of a national working group led by NHS Improvement which has been tasked with developing a model for the review and classification of deaths and has amended its data systems as per national guidance
  • Engaged with the lead Clinical Commissioning Group (Liverpool) to ensure their Head of Risk is a member of the Trust Mortality Review Group and participates fully in decision making
  • Presented work to the Clinical Commissioning Group’s Clinical Quality Performance Group (CQPG) who were supportive of the actions to date
  • Plans are in place to incorporate mortality into the Trust’s 2016/7 Quality Account
  • Commissioned Mazars to support implementation of new systems
  • All staff are giving regular briefings on investigations on deaths in care.



“The Review specifically emphasises a focus on learning disability and mental health patients and while Mersey Care is fully committed to engaging and working together to provide better patient care, we remain concerned about the parity of funding that restricts progress in mental health care. We believe that our work with Stanford Risk Authority will enable us to better predict harm, and manage risk earlier for our patients and service users.


“Mersey Care has also recently established a Specialist Learning Disability division of the Trust and has been awarded the highest rating under the Triangle of Care system formulated by the Carers’ Trust, which strengthens our partnership with the families and carers of our service users and patients.


“We have focussed a great deal on driving learning throughout the organisation and as a result, became the first mental health trust in the country to publicly commit to a zero suicide policy last year. As an extension of this for the last 12 months, we have made both the investigation and prevention of deaths in our care a strategic priority as part of our commitment to ‘Perfect Care.’


“For example, in practical terms, we are driving to rapidly improve physical health and wellbeing in our patients – another key strand of our Perfect Care strategy – and are working alongside Liverpool Heart and Chest Hospital that will allow the collective response of hospitals anticipated by this Review.


“We recognise the importance of committing to a ‘Just Culture’ throughout the Trust, which is consistent with the recommendations in the Review that ‘Candour, Accountability and Learning’ are all inter-connected and should not be seen as separate endeavours.”