Response to the Care Quality Commission's Learning from deaths report

Rob Behrens, Parliamentary and Health Service Ombudsman responds to today's publication of the Care Quality Commission's Learning from deaths report:

'Time and time again we find NHS investigations into avoidable deaths inadequate, causing further suffering to families who have lost their loved ones.

'People shouldn’t have to come to the Ombudsman to establish what has happened to their loved ones, as health services should be able to carry out high-quality investigations and learn from what went wrong.

'The CQC's Review shows some welcome signs of progress but the NHS must encourage a more open culture, where staff do not fear reprisals, to improve the quality of its investigations and learn from mistakes.’