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Investigation and Learning from Deaths in NHS Trusts

Friday 15 November 2019
De Vere West One Conference Centre, London

Investigation and Learning from Deaths in NHS Trusts
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The NHS is the world’s first health organisation to publish data on avoidable deaths. The National Guidance on Learning from Deaths has driven a strengthening of systems of mortality case review with emphasis on learning. 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.

The conference will also discuss the role of Medical Examiners which were introduced in April 2019, providing a national system of medical examiners will be introduced to provide much-needed support for bereaved families and to improve patient safety. 

“Care Quality Commission (CQC) inspections have shown good progress is being made by some NHS hospital trusts to implement national guidance on learning from deaths. However, failure to fully embrace an open, learning culture may be holding organisations back from making the required changes at the pace needed…  the amount of progress made to date varies between trusts and CQC analysis suggests that some organisations have found it harder than others to make the changes needed.” Care Quality Commission March 2019

“Through our well led inspections we have seen trusts that have made positive changes to ensure that learning from deaths is given the priority it deserves…However, the speed of progress varies, and our review indicates that problems with the culture of some organisations is preventing sufficient progress. Cultural change is not easy and will take time, but we cannot lose momentum and the current pace of change is not fast enough... We will continue to assess the progress trusts are making through our inspection and monitoring and to hold trusts to account when we find improvements are required.” Professor Ted Baker, CQC’s Chief Inspector of Hospitals, March 2019 

Attendance at this conference will support you to:

  • Network with colleagues who are working to improve practice in the investigation and learning from deaths
  • Learning from the National Mortality Case Review Programme
  • Reflect on the lived experience of a carer 
  • 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?
  • Understand national developments and national reporting requirements
  • Learn from best practice in the investigation of deaths
  • Identification and reporting of deaths and the role of the Medical Examiner
  • Improving your processes and skills in 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
  • 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


 

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