INVESTIGATIONS into the deaths of patients within a mental health trust in Cumbria were among those considered as part of a damning national review into NHS complaints.
A team of experts from government health watchdog the Care Quality Commission visited the Cumbria Partnership NHS Foundation Trust this summer as they gathered information on how complaints over patient deaths are handled.
Their final Learning, Candour and Accountability report, published for the first time yesterday, concludes not a single trust across the country has got it right when it comes to dealing with bereaved families.
It goes on to say the relatives of those who die while under NHS care are often left in the dark while their complaints are explored by 'defensive' healthcare bosses.
CPFT, which runs community hospitals and mental health services across Cumbria, including the inpatient Dane Garth facility at Barrow's Furness General Hospital, was one of four mental health trusts in the country visited by the inspection team.
Speaking on behalf of the trust, medical director Dr Andrew Brittlebank welcomed the new report adding that learning from the deaths of patients is a key priority for the organisation.
"Within CPFT we have always had a focus on learning from serious incidents and over the last two years this has been a priority area for the trust.
"During this time we have made a number of improvements to how we identify, investigate and most importantly learn from serious incidents."
Dr Brittlebank went on: "However we are aware that there are still areas that we need give more consideration to, including developing our recently established Mortality Review Group to ensure learning from all deaths, completing more investigations within the national timescale of 60 working days, and ensuring families and carers are involved in the investigation process at the earliest opportunity."
Prior to 2014, the trust found itself at the centre of criticisms over failings in care which were found to have contributed to a number of tragic deaths.
They included that of south Cumbria teenager Helena Farrell, 15, in 2013, and Dalton schoolboy Harry Hucknall, aged 10, who died in 2010.
Both had been referred to Barrow's Children and Adolescent Mental Health Service in Barrow.
A third case involved the death of Barrow father of one Justin Forsyte, 41, who died after he was released from the Dane Garth mental health unit following a 'substandard' assessment.
Government health secretary Jeremy Hunt, who commissioned the report, has now promised to implement a raft of measures to improve the way patient deaths are investigated by hospitals and community and mental health trusts.
They will include a national process for investigation adopted nationwide - while a member of the board of directors at every trust will be given responsibility for ensuring the investigations are carried out to the approved standard.
Hospitals will also be asked to publish figures on the number of avoidable deaths under their care every quarter while families will be involved at a much earlier stage.
Professor Sir Mike Richards, the CQC’s chief inspector of hospitals, said: "Families and carers are not always properly involved in the investigations process or treated with the respect they deserve.
"We found this was particularly the case for families and carers of people with a mental health problem or learning disability which meant that these deaths were not always identified, well investigated or learnt from."
READ MORE: Eight deaths in secure mental health wards reported in Cumbria
READ MORE: Tragic Harry's final farewell to his family
Comments: Our rules
We want our comments to be a lively and valuable part of our community - a place where readers can debate and engage with the most important local issues. The ability to comment on our stories is a privilege, not a right, however, and that privilege may be withdrawn if it is abused or misused.
Please report any comments that break our rules.
Read the rules here