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Learning from deaths

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The National Quality Board has published new guidance for NHS trusts on learning from deaths. 

The CQC are strengthening their assessment of providers learning from deaths including the processes required and the engagement of families and carers.

Trusts are required by the guidance to:

  • Have a policy in place to show that they are learning from deaths by September 2017. This needs to cover:
    • How they deal with the death of someone with a learning disability or mental health needs, a child or infant and stillbirths/maternal deaths.
    • How they undertake case record reviews. 
    • How they select deaths which will be reviewed. As a minimum this needs to include patients set out at the first bullet point.
  • Cover every death by the death certification process, a case record review and/or an investigation (guided by the existing serious incident framework).
  • Case record reviews must be carried out in a relatively wide set of specified circumstances, such as deaths during elective procedures or deaths where family members have raised concerns about the quality of care. A sample of deaths which don’t meet the criteria should also be subject to a case record review.
  • Have a system for deriving and acting on learning from reviews and investigations.
  • Have governance arrangements and processes which cover and give ‘due focus’ to the review, investigation and reporting of deaths.
  • Provide appropriate training on the above for staff.
  • Have policies in place regarding engagement with families and carers of deceased patients, including the opportunity to ask questions or raise concerns about the quality of care provided.
  • Provide a quarterly report regarding deaths via a paper and an agenda item to a public board meeting. From June 2018 this will also need to be published in quality accounts.

Many trusts will already have systems up and running which allow them to comply with the guidance. It remains to be seen what practical effect the guidance will have; however this is likely to lead to a larger number of cases requiring some form of review. 

We have a range of training options available for trusts covering this guidance as well as duty of candour obligations and patient engagement.

Contact us for more details.

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