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Investigation and Learning from Deaths

Fri, 14 Jun 2024

Virtual, Online

Follow the conference on X #LearningFromDeaths

This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts. 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. There will be an extended focus on engaging and involving patients, families and staff following a death, and on learning from deaths including an update from a coroner.

By 2024, all deaths in the community or acute settings that do not required to be referred to the coroner (non-coronial deaths) will need to be scrutinised by a medical examiner.

The conference 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 conference will also include a split stream where delegates can chose to focus on investigating and learning from either deaths in acute care, or deaths in primary and community care.

The conference will also update delegates on the New National Patient Safety Incident Response Framework which was published on 16th August 2022 and the implications for serious incident investigation and learning from deaths.

“The majority of in-hospital deaths are now scrutinised and the process is rolling out to include all community deaths. It is expected that the process will become statutory by 2024 when every death within England and Wales will be reviewed either by the Medical Examiner or HM Coroner.”

The Medical Examiner: reviewing all non-coronial deaths in England and Wales, July 2023

“Medical examiners will look at causes of all deaths not investigated by the coroner to help prevent criminal activity and poor practice… Medical examiners will strengthen safeguards by scrutinising how people have died prior to registration and make sure the right deaths are referred to coroners.”

Department of Health and Social Care 14th December 2023

“The move to a statutory system in 2024 will further strengthen those safeguards, ensuring that all deaths are reviewed and the voices of all bereaved people are heard.”

Dr Suzy Lishman, Senior Medical Adviser on Medical Examiners for the Royal College of Pathologists 14th December 2023

Attendance at this conference will support you to:

  • Network with colleagues who are working to improve practice in the investigation and learning from deaths

  • Improve practice in learning from deaths 

  • Reflect on the involvement of families through a 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?

  • Implement the new Patient Safety Incident Response Framework and improve learning from serious incidents

  • 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 the Coroner perspective and role 

  • Understand the decision to investigate, and the appropriate level of investigation

  • Explore how a human factors can support learning from deaths

  • Effectively support staff when a death occurs including supporting staff through coroner inquests and serious incident investigations 

  • Self assess your learning from deaths process and ensure investigations lead to change

  • Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes

Speakers include:

Dr Jason Shannon

Lead Medical Examiner, Wales
NHS Wales Shared Service Partnership

Ms Nadia Persaud

Area Coroner
East London
Her Majesty's Coroners East London

Mr Mike O'Connell

Legal Services Practitioner and Interim Senior Inquests Manager
Calderdale and Huddersfield NHS Foundation Trust

Mr Julian Hendy

Co Founder & Member and Founder
Making Families Count CIC

Ms Tracy Ward

Head of Patient Safety
Leicestershire Partnership NHS Trust

Exhibition & Sponsorship Packages

This conference offers a valuable opportunity for industry suppliers to personally meet with their target audience where they will have time to talk and demonstrate the benefits of their products. High quality specialist audiences make having a presence at our events a highly targeted and cost effective marketing channel.

Why Exhibit?

Having a presence at this event will give you the opportunity to:

  • Demonstrate your product, system or service
  • Network and engage with your key audience  
  • Generate new business leads
  • Gain exposure for your brand and raise the profile of your organisation
  • Understand the current needs of your audience and challenges they’re facing
  • Update your knowledge of national policy and local developments  


Contact Sarah Jane for exhibition and sponsorship prices, or to discuss a tailored package to suit your needs and budget.

Fee Options

Virtual NHS, Schools, Care and Public Sector



Virtual Voluntary sector & charities



Virtual Commercial organisations



(Prices in brackets include VAT)


Additional delegate discount:

A discount of 15% will be applied to fees for any extra delegates.

Online discount:

A discount of 10% will be applied if you pay using the website.

Also of Interest

Supporting Organisations

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