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Learning from deaths while in the NHS: CQC recommendations

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

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 Dec 2016).

“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 Dec 2016

Forthcoming conferences looking at implementing the recommendations from the CQC report include:

Investigation of Deaths & Serious Incidents in Mental Health Services
Friday 10 February 
De Vere West One, London

Hospital Mortality National Summit: Mortality Monitoring & Reducing Avoidable Deaths attributable to problems in care - where are we now?
Wednesday 22 February 
The Studio Conference Centre, Birmingham

Learning from Serious Incidents: Implementing the CQC Recommendations
Thursday 23 February 
The Studio Conference Centre, Birmingham


13 December 2016


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