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Signs of progress on learning from deaths - but a more open learning culture is needed across the NHS to drive further improvement

18 March 2019
  • Media

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.

In a report published today (Tuesday 19 March) CQC reviews inspectors’ observations from the first year of assessing how well trusts are implementing national guidance introduced to support improved investigations and better family engagement when patients die.

National guidance for trusts to initiate a standardised approach to learning from deaths was published by the National Quality Board (NQB) in March 2017, followed by guidance for trusts on working with families in July 2018. Both documents were introduced in response to the findings of CQC’s 2016 thematic review Learning, candour and accountability which made a number of recommendations to help to improve the quality of investigations into patient deaths.

The NQB’s national guidance called for trusts to improve processes for identifying deaths resulting from problems in care, to introduce a clear policy for engaging with bereaved families and carers in a meaningful and compassionate way, and to appoint a senior member of staff to hold responsibility for learning from deaths across the organisation. It also set specific requirements for trusts to collect and report information about deaths of patients in their care.

CQC’s review reveals that a year on, awareness of the guidance is high, and inspections have found evidence of some trusts having taken action to revise policies and establish more robust oversight of the investigation process to ensure learning is shared and acted on.

Overall, CQC found that the key to enabling good practice is an open and learning culture, clear and consistent leadership, values and behaviours that encourage engagement with families and carers, positive relationships with other organisations and the ability to support staff with training and the wider resources needed to carry out thorough reviews and investigations. CQC’s report highlights specific examples of hospital trusts where these factors have been pivotal in supporting compliance with the requirements of the guidance.

However, 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. In particular, improving engagement with bereaved families and carers is an area where some trusts have struggled. Issues such as fear of engaging with bereaved families, lack of staff training, and concerns about repercussions on professional careers, suggest that problems with the culture of some organisations may be a barrier to putting the guidance into practice.

Professor Ted Baker, CQC’s Chief Inspector of Hospitals, said:

“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. For example, freeing staff up from clinical commitments to focus on implementing the national guidance, introducing clear processes for engaging with families and carers, and strengthening the governance and oversight of mortality reviews.

“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.

“I urge NHS trusts to use the examples of good practice highlighted in this report to help identify the key drivers to improve learning from deaths, to build on the progress they have made so far and to accelerate the changes needed. 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.”

“Alongside this, there needs to be continued support from the centre, including support for behaviours that encourage more openness and learning across the NHS, clearer guidance for community and mental health trusts, and a more focused consideration of the progress being made on reviews and investigations of deaths of people with mental health problems or a learning disability which was highlighted as a priority in our original thematic review.”

Miriam Deakin, NHS Providers Director of Policy and Strategy, said:

“When a person dies under NHS care it is vital to ensure that opportunities to learn and improve care are not missed.

“It is encouraging to see that trusts’ awareness of new national guidance on learning from deaths is high, and that some – though not all – have made good progress.

“We welcome this report which offers practical examples of good practice by trusts, together with useful insights on the changes needed to support a better approach.”

CQC has been assessing how well acute, community and mental health trusts are implementing national guidance on learning from deaths as part of its annual well-led inspections since September 2017.

CQC’s report Learning from Deaths - a review of the first year of NHS trusts implementing the national guidance is based on interviews and focus groups with CQC inspectors and specialist advisors involved in well-led inspections between September 2017 and June 2018. It also draws on a case study analysis of three NHS hospital trusts that have demonstrated areas of good practice in implementing changes to improve investigations and learning when patients in their care die.

Following this review CQC has committed to further strengthening its assessment of how trusts are investigating and learning from patient deaths and to providing additional support and training for inspection staff involved in monitoring and inspecting trusts progress.


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Last updated:
19 March 2019

Notes to editors

  1. A full copy of CQC's report, ‘Learning from deaths – a review of the first year if NHS trusts implementing the national guidance’ will be available from 00.01 Tuesday 19 March 2019 from CQC's website at A link to an embargoed copy of the report is available at the bottom of this email.
  2. The report is based on information gathered through interviews and focus groups with CQC inspection staff and specialist advisors that had been involved in at least one well led trust inspections since September 2017.
  3. All interviews and group discussions were conducted between September 2017 and June 2018 and were focused specifically on understanding the quality of trust implementation of national guidance on learning from deaths.
  4. The review was also informed by discussions with representatives from NHS trusts, families and carers and a range of stakeholder organisations.

About the Care Quality Commission

The Care Quality Commission (CQC) is the independent regulator of health and social care in England.

We make sure health and social care services provide people with safe, effective, compassionate, high-quality care and we encourage care services to improve.

We monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and we publish what we find to help people choose care.