How can we assess how well providers review, investigate and learn from deaths?

Published: 16 June 2017 Page last updated: 12 May 2022

We'd like your views on how we can strengthen the way we look at whether NHS trusts learn from deaths to improve the care they provide.

We'd particularly like to hear from families and carers, but we're interested in the views of health professionals too. You can tell us what you think by taking part in our online survey. The survey closes at 6pm on 14 July.

Our report: Learning, candour and accountability

In December we published our national report Learning, candour and accountability, which looked at how NHS trusts review, investigate and learn from deaths. We found that:

  • families and carers often have a poor experience of investigations and are not always treated with respect, sensitivity and honesty.
  • there's no single framework for NHS trusts that sets out what they need to do to learn from deaths that may be the result of a problem in care.
  • none of the trusts we looked at could demonstrate good practice across all aspects of identifying, reviewing and learning from deaths. 

Our report made eight recommendations. The Secretary of State accepted all of them and committed to making this work a national priority.

What we've done since December

One of the recommendations was that we strengthen the way we look at how providers identify and investigate the deaths of patients. This particularly includes how families and carers are involved in investigations, the quality of investigations, and how providers learn from deaths and the action they take. It also recommended a focus on patients with a learning disability or mental health problem.

We've been working on how we can put this into practice in our inspections, and now we're ready to ask your views on our proposals so far.

What we're proposing

To begin with, this will apply to NHS-funded acute care, community healthcare, mental health services and learning disability services. We're planning to introduce similar changes to our inspections of GP practices, adult social care, independent healthcare and ambulance NHS trusts in 2018.

We aim to:

  • help NHS trusts to move towards a culture where learning from deaths becomes an ordinary part of what they do, and where families are given a clear account of what happened and where things could have been done better.
  • identify anything that needs to change immediately to protect people.
  • develop more systematic methods that we can use to monitor and inspect services.
  • show what good practice looks like so that care providers understand what they are good at, as well as where they need to improve.
  • ensure our work dovetails with guidance and support provided by other organisations such as NHS Improvement.

The questions we're planning to ask

The questions we're planning to ask care providers are similar to the ones we used when we were gathering evidence for our report:

  • How do you involve families and carers?
  • How do you identify which cases to review?
  • What process do you use to investigate deaths?
  • How do you invest in training and support for deaths investigations?
  • What governance arrangements do you have to make sure you learn from deaths to improve the care you provide?

We'll use these questions as part of our new assessments of how well-led an NHS service is. We'll be carrying out this type of assessment in every NHS trust between this autumn and March 2019, and once a year after that. There are three main parts to the approach we're proposing.

  1. Monitoring and relationship management. We plan to find out what families and carers are saying by using sources like local Healthwatch, PHSO investigation findings, Patient Liaison Services (PALS), Clinical Commissioning Groups, Bereavement Services and NHS trust meetings. We will also gather information that NHS trusts are now required to collect on the numbers of deaths of patients, those that have been reviewed thoroughly and estimates of how many deaths were judged more likely than not to have been due to problems in care.
  2. Risk-based reviews of investigations of individual deaths. Where there are concerns – either raised by families or carers, or from other information – we will review a sample of up to four cases of deaths that have been investigated, selected randomly by the inspection team. These will include a person with a learning disability and person with a mental health need, where these can be identified. We want your views on how this activity should be triggered.
  3. Inspection interviews. We'll look at trust policies and procedures. We'll also interview the board member and executive who leads on learning from deaths, the operational lead on quality and safety and some of those who investigate cases. We also need to capture the views of families and carers.

We will assess findings against a new key line of enquiry which is now part of the 'well-led' assessment and rating:

"How effective is participation in and learning from internal and external reviews, including those related to mortality or the death of a service user? Is learning shared effectively and used to make improvements?"

Tell us what you think

We'd like to hear what you think of our proposals.

Complete our survey

Read our report

Learning, candour and accountability