Today, the Care Quality Commission (CQC) published the findings of a review into whether the deaths of people in care are reported and investigated properly. This follows from investigations into Southern Health NHS Foundation Trust earlier this year. The review looked particularly at people with mental health conditions or a learning disability who had died in health settings.

Any unexpected death is a tragedy, and so it is important that NHS trusts and organisations in positions of care and power find out what went wrong. This way they can stop it happening again.

But this report found that investigations across England were patchy and families were not always listened to. Importantly, it also found that when people were getting care from several organisations, that information wasn’t shared between them. This meant that they weren’t able to consider if an investigation should be carried out.

To address this situation, the CQC has recommended that a new nationwide system should be developed. This would create a consistent approach to when investigations are carried out. The CQC has also called for this to make sure that families are informed and involved in investigations about the deaths of their loved ones. 

This is an important report about a very serious issue. The National Autistic Society thinks it is crucial that the Government acts on the CQC’s recommendations. We have also made a comment to the media:

Mark Lever, Chief Executive of The National Autistic Society, said: “This report by the Care Quality Commission into the investigation of unexpected deaths in England will be extremely upsetting for anyone who has lost a loved one in care and should prompt urgent action.

“The review looked at unexpected deaths in health settings and had a specific focus on the deaths of people with a mental health condition or a learning disability, many of whom are on the autism spectrum. It highlights an alarming failure to investigate these deaths, which should always be subject to close and thorough scrutiny. It is deeply shocking that not one of the NHS trusts in the review is getting the whole investigation process right. 

“Any unexpected death is a tragedy and we should expect that families going through this horrible loss are treated with kindness, respect and sensitivity during the investigation. However, as confirmed by this report, we know that far too often this is not the case. 

“We welcome the recommendation to develop one single framework which can standardise and improve practice across the country. We also welcome the call for consistent support and involvement for bereaved families and carers, which is crucial. 

“The Government must respond to these recommendations and act immediately. We will be watching closely for improvements being put in place which will reassure families that mistakes from the past will not be allowed to happen again.”

We know this story may be upsetting. If you would like advice on about care and support of an autistic person, please contact our Helpline. Please note, the helpline is open 10am-4pm Monday-Thursday and 9am-3pm on Friday.