Register external reviews with CQC

43. We accept these recommendations. A new national, Independent Patient Safety Investigation Service will improve local standards of investigation and openness. 44. During the 10-year period in which serious incidents were occurring at Morecambe Bay, the Investigation found that there had been external reviews conducted into operational aspects of the Trust, that were not brought to light in a timely or transparent way and that had regulators been sighted on the Fielding report earlier, action might have been taken sooner to address concerns. 45. NHS Trusts and Foundation Trusts are already required to notify the Care Quality Commission and Monitor and the NHS Trust Development Authority of certain events, such as serious incidents or third party investigations or reports. However we also believe that there is a strong case for requiring providers to notify regulators - both the Care Quality Commission and Monitor or the NHS Trust Development Authority - when they commission external investigations. The Government will consult on proposals to extend the regulations that set out requirements for notifications to cover the commissioning of external investigations. 46. In the meantime, Monitor and the Care Quality Commission will continue to use their respective statutory information-gathering powers to require NHS Trusts and Foundation Trusts to notify them of both the commissioning and the conclusions of relevant external investigations. 47. Trusts also have to report in their Quality Account on the number and where available, the rate of patient safety incidents reported within the reporting period, and the number and percentage of such patient safety incidents that resulted in severe harm or death. There is also a requirement to report on whether they have taken part in any reviews or investigations by the Care Quality Commission under section 48 of Health and Social Care Act 2008. We will consider what more can be done to improve awareness and accessibility of this information. 48. There are several existing mechanisms for reporting and sharing learning from serious incidents: • NHS bodies are already required to notify the Care Quality Commission and the National Reporting and Learning System, currently overseen by NHS England, where serious incidents have happened, including those which prompt investigations. Reports to the National Reporting and Learning System are analysed by expert clinicians to identify common hazards, and can result in recommendations being made to local NHS organisations to mitigate these risks and improve the safety of patient care. • The NHS England Serious Incident Framework recommends that providers collaborate with external scrutiny and investigations, including the full and open exchange of information with other investigatory agencies (such as the police, the Health and Safety Executive, Coroner and local safeguarding boards). It also recommends publishing information about serious incidents including data on the numbers and types of incidents, excluding material that would compromise patient confidentiality, within annual reports, board reports and other public facing documents. 49. The Government have accepted the recommendation of Sir Robert Francis QC that national expertise on patient safety should be based within a single organisation that can provide strategic leadership across the whole healthcare system. The Government intend to bring under the single leadership of Monitor and the NHS Trust Development Authority responsibility for leading the patient safety functions that currently sit with NHS England. The new Independent Patient Safety Investigation Service will also be brought under the single leadership of Monitor and the NHS Trust Development Authority. A core element of that role would be supporting the NHS to learn from service failures. Responsibility for disseminating learning from external investigations would best sit with the body that has the lead role on patient safety.

NHS England and CQC use Joint System Oversight Groups (JSOGs) to review quality issues and risks at providers.

The Academy of Royal Colleges published their updated invited review framework in March 2022. Principle 14 of the framework sets out that healthcare organisations will be responsible for addressing patient safety risks and being open and transparent about them. This includes bringing risks identified in the review to the attention of the CQC and other appropriate regulatory bodies.

With regards to disseminating learning, In March 2019 CQC published Learning from Deaths: A review of the first year of NHS trusts implementing the national guidance.

Department of Health response (July 2015):

“The Government will consult on proposals to extend the regulations that set out requirements for notifications to cover the commissioning of external investigations.” (p. 75) Although unable to find government proposal, the Care Quality Commission webpage states that disclosure of commissioning any external revies should be disclosed as a “matter of course” which is unclear whether this is a statutory obligation or suggested guidance. Also this does not form part of the notifications that are meant to go to the Care Quality Commission.