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Investigation and Learning from Deaths in NHS Trusts

Monday 14 May 2018
De Vere West One Conference Centre, London

Investigation and Learning from Deaths in NHS Trusts
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“The requirement on organisations is clear. It is not simply to have a robust process for reviewing deaths in care, important though this is. Trusts need also to engage with and support bereaved families, to provide mechanisms for staff support and debriefing and to ensure active and robust board oversight. Perhaps most importantly learning needs to be translated into sustainable action to improve the way we look after the people in our care… We recognise there is more to do to ensure that the NHS truly draws on all possible learning from the deaths of those in its care.” Dr Kathy McClean, Medical Director NHS Improvement, December 2017

“The NHS is the first healthcare system to commit to reporting and publishing information on the number of avoidable deaths in its hospitals and the work that is being done by individual NHS trusts to learn from those deaths. This new level of transparency will be central to improving care and ensuring the safety of the NHS services we all rely on…We will use this information alongside the findings of our inspections to identify where providers must make improvements and to share good practice where we find hospitals that are doing it well…the challenge now is to deliver the full vision of a safer learning culture that was laid out in ‘Learning, Candour and Accountability so that learning from deaths becomes an accepted part of practice that provides answers for families and drives improvements in the quality and safety of care.” Prof Ted Baker, Chief Inspector of Hospitals, Care Quality Commission, December 2017

The Department of Health have recently confirmed that the NHS is to become the world’s first health organisation to publish data on avoidable deaths. The data will not be collated centrally, and each trust will be required to make its own assessment of the number of deaths due to problems in care, which will allow trusts to focus on learning from mistakes and sharing lessons locally. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death.

This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts following the National CQC and NQB guidance, and Department of Health reporting requirements.

Attendance at this conference will support you to:

  • Network with colleagues who are working to improve practice in the investigation and learning from deaths
  • Understand national developments and national reporting requirements  
  • Learn from best practice in the investigation of deaths  
  • Improving your processes around mortality review and mortality governance  
  • Reflect on how you improving involvement of families and carers
  • Understand the decision to investigate, and the appropriate level of investigation  
  • Improving your skills in serious Incident Investigation: applying the serious incident framework and using skilled analysis to move the focus of investigation from acts or omissions of staff, to identifying the underlying causes of the incident 
  • Learn from working examples of mortality governance and develop the role of mortality audits, internal inspection and mortality reviews to answer the question “did a problem in care contribute to the death?
  • Implementing and integrating a Learning from Deaths dashboard
  • Self assess your learning from deaths process and ensure investigations lead to change
  • Gain CPD accreditation points contributing to professional development and revalidation evidence

 

“A year since the Care Quality Commission published Learning, candour and accountability: A review of the way NHS trusts review and investigate the deaths of patients in England and nine months since the National Quality Board issued National guidance on Learning from Deaths in March 2017, there has been a significant shift in expectation about how trusts should respond to, review and learn from the deaths of people in their care” Dr Kathy McClean, Medical Director NHS Improvement, December 2017

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