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Investigation and Learning from Deaths in NHS Trusts

Friday 8 February 2019
De Vere West One Conference Centre, London

Follow the conference on Twitter #CQCDeathsreview

“Just under half of deaths in England occur in hospital and around one in three hospital beds is occupied by someone who is in the last 12 months of their life…Learning from Deaths required all trusts to carry out mortality reviews by 2017 and to publish a quarterly dashboard reporting their data on deaths, including data on preventable deaths and reports on their actions to learn and improve.” National Mortality Case Record Review Programme Annual Report 2018

“Learning from deaths of people in their care can help providers improve the quality of the care they provide to patients and their families, and identify where they could do more. A CQC review… ‘Learning, candour and accountability: a review of the way trusts review and investigate the deaths of patients in England’ found that some providers were not giving learning from deaths sufficient priority and so were missing valuable opportunities to identify and make improvements in quality of care.” NHS Improvement 2018

“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.” Kathy McLean Executive Medical Director, NHS Improvement 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

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.

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 
• 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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