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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 and will reflect on learning from deaths during the Covid pandemic and how mortality investigation should be managed in these cases.
The conference, chaired by Dr Martin Farrier, Associate Medical Director & Consultant Paediatrician, Wrightington, Wigan and Leigh NHS Foundation Trust, will discuss the role of Medical Examiners in learning from deaths which is now being extended to all non-coronial deaths wherever they occur.
“The objective is for medical examiners to independently scrutinise all non-coronial deaths across England and Wales”
“it is appropriate for all medical examiner offices in England to begin a process to extend medical examiner scrutiny to all non-coronial deaths wherever they occur… We do not underestimate the complexity of this next phase of implementation, nor the challenges it will present.”
“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.”
“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.”
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 Mortality Case Review
- Reflect on the lived experience of a carer
- Learning from deaths during Covid-19
- 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 – including extending this role to all non-coronial deaths
- 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: and understanding the implications of the New Patient Safety Incident Response Framework
- Explore how a human factors can support learning from deaths
- Effectively support staff when a death occurs including supporting staff through coroner inquests
- Self assess your learning from deaths process and ensure investigations lead to change
- Gain CPD accreditation points contributing to professional development and revalidation evidence
