Learning From Deaths

In this section you will find: 

  • Introduction
  • Trust Reports 
  • Learning From Deaths Policy GR47
  • Top 10 Tips for Family Engagement

Introduction

In March 2017, the National Quality Board published the first edition of the National Guidance on Learning from Deaths to help standardise and improve the way that NHS trusts identify report, review, investigate and learn from deaths, and how they engage with bereaved families and carers.

This was reinforced by the findings of the Care Quality Commission (CQC) report Learning, candour and accountability: A review of the way NHS trusts review and investigate the deaths of patients in England published in December 2016.  It found that learning from deaths was not being given sufficient priority in some organisations and consequently valuable opportunities for improvements were being missed. The report also pointed out that there is more that the NHS can do to engage families and carers and to recognise their insights as a vital source of learning. Its purpose is to help initiate a standardised approach, which will evolve as the health care system learns.

NHS Improvement has published further guidance, ‘Implementing the Learning from Deaths framework: key requirements for Trust boards’NHS Improvement is encouraging trusts to learn from each other and challenge each other to continuously improve the quality of their Learning from Deaths processes and the implementation of effective and sustainable improvements as a result.  NHS England is also leading work to further determine what support bereaved relatives and carers can expect from trusts, this is due to be published in 2018.  Cheshire and Wirral Partnership NHS Foundation Trust has consulted and worked with trusts across the Cheshire and Merseyside footprint to ensure a whole systems approach to overseeing implementation and sharing processes as we evolve.

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