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Investigation of Deaths in NHS Trusts: Implementing the CQC Recommendations

Monday 8 May 2017
De Vere West One Conference Centre, London

Investigation of Deaths in NHS Trusts: Implementing the CQC Recommendations
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Implementing the National Guidance on Learning from Deaths released by the National Quality Board in March 2017.  “The National Quality Board has published a first edition of National Guidance on Learning from Deaths, providing a framework for NHS trusts on identifying, reporting, investigating and learning from deaths of people in their care. The need for national guidance was identified as one of the highest priority recommendations in our report Learning, Candour and Accountability, published in December last year. Earlier this month, more than 450 senior executive and non-executive directors of trusts, plus family and carer representatives met to discuss how this guidance should be implemented.”

“Learning from deaths needs much greater priority within the NHS to avoid missing opportunities to improve care.” CQC, 13 December 2016

“There is a real opportunity for the NHS to become world leaders in the way learning and investigations are completed and changes are made when a person dies… We call on everyone working in and with the NHS to play their part in making the changes needed, with a focus on pace, transparency and consistency being achieved in 2017.” CQC, 13 December 2016

The Care Quality Commission released their report and recommendations into learning from deaths while in the NHS on Tuesday 13th December 2016.

Sir Mike Richards, the CQC’s chief inspector of hospitals, said: “The extent of the problems is more than I expected. The whole system [of investigating deaths] needs an overhaul at national level and local level.” He added that “there is not a single NHS trust that is getting it completely right currently”. HSJ, December 2016

“Learning from the care provided to patients who die is, of course, a key part of clinical governance and quality improvement work. These new requirements are designed to complement your existing approaches, introducing minimum standards and reporting in some areas but not seeking to replace current good practice” Care Quality Commission and NHS Improvement 22nd February 2017

“Learning from deaths needs much greater priority across the health and social care system. Without this, opportunities to improve care for future patients will continue to be missed…. Healthcare providers should have a consistent approach to identifying and reporting, investigating and learning from the deaths of people using their services, and when appropriate, sharing this information with other services involved in a patient’s care before their death… Bereaved relatives and carers must always be treated as equal partners and receive an honest and caring response from health and social care providers. … Reviews and investigations need to be carried out to a high quality, with a focus on system analysis rather than individual errors.” Care Quality Commission, December 2016

The Care Quality Commission identified five recommendations following their review

  1. Involvement of families and carers 
  2. Identification and reporting 
  3. Decision to review or investigate
  4. Reviews and investigations
  5. Governance and learning

Through national updates, expert sessions and practical case studies this conference will demonstrate how to effectively implement the CQC recommendations in practice.

“From next year we will then become the first country in the world to publish data on avoidable deaths at a hospital by hospital level.” Jeremy Hunt, Minister of State for Health, 13 December 2016

The Department of Health stated on 13th December 2016 that from March 31 next year the Boards of all NHS Trusts and Foundation Trusts will be required to:

  • Collect a range of specified information on deaths that were potentially avoidable and serious incidents and consider what lessons need to be learned on a regular basis.
  • We will be requiring Trusts to publish that information quarterly
  • Alongside that data, they will publish evidence of learning and action‎ that is happening as a consequence of that information.
  • They will feed the information back to NHS Improvement at a national level, so that the whole NHS can learn more rapidly from individual incidents.
  • All Trusts will be asked to identify a board-level leader as patient safety director to take responsibility for this agenda
  • We will ensure that investigations of any deaths that may be the result of problems in care are more thorough and genuinely involve families and carers.
  • all Trusts will be asked to follow a standardised national framework for identifying potentially avoidable deaths, reviewing the care provided, and learning from mistakes.


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