Ombudsman comment on CQC review of NHS investigations into deaths

Following the Care Quality Commission’s (CQC) review of NHS investigations into deaths published today, the Parliamentary and Health Service Ombudsman can reveal that it has upheld 338 complaints into avoidable deaths in 2016 to date, compared to 306 complaints in 2015.

Commenting on the CQC report, Parliamentary and Health Service Ombudsman Julie Mellor, said:

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

'Robust and effective investigations can only happen if NHS staff are properly trained. This report is a golden opportunity for NHS leaders to learn from mistakes and encourage an open, honest working environment where NHS staff do not fear reprisals.'


  • In our 2015 review of NHS investigations into serious harm, we found that nearly three quarters of hospital investigations into complaints about avoidable harm and death claimed there were no failings in the care given, despite our investigations of the same incidents uncovering serious failings.
  • In our 2016 Learning from Mistakes report, we identified wider systemic lessons for the NHS, focusing on the need for the NHS to move from a culture of fear over mistakes to one that embraces learning and improves the competence and co-ordination of investigations.