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Investigation and Learning from Deaths in NHS Trusts

Learning from deaths

Dr Jason Shannon
Lead Medical Examiner
Wales, NHS Wales Shared Service Partnership


• learning from deaths
• ensuring learning from the mortality review process, incidents and investigations leads to sustainable improvements in quality or safety
• learning from Covid-19
• developing the role of the Medical Examiner
• extending medical examiner scrutiny to all non-coronial deaths wherever they occur
• our experience


Evaluating the implementation of the Learning from Deaths Programme

Dr Zoe Brummel
Anaesthetic and Intensive Care Trainee
University College London NHS Foundation Trust

• reviewing how organisations are using the LfDs programme to learn from and prevent, potentially preventable deaths
• themes and lessons from the findings


Working with and involving families when a death occurs

Julian Hendy
Founder, Hundred Families
Co Founder & Member, Making Families Count

• learning from the lived experience
• how can we put patients and carers at the heart of the process?
• how excellent family engagement can produce better results for family and Trust during serious incident investigations
• involvement in reviews and investigations: what does excellence look like?
• implementing the new national guidance in practice

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