What's happened since our review of how NHS trusts investigate and learn from deaths?

Published: 22 March 2017 Page last updated: 12 May 2022

Following our review last year of the way NHS trusts investigate the deaths of patients, we published our report 'Learning, candour and accountability' in December 2016.

This made a number of recommendations to help to improve the quality of investigations when people die and ensure safer services for future patients. These recommendations were accepted in full by the Secretary of State.

The recommendations are currently being taken forward by the Department of Health and the National Quality Board (NQB) with input from a number of organisations, including CQC, NHS England, NHS Digital and NHS Improvement.

One of our key recommendations was that national guidance should be developed. This guidance has been produced by the NQB and the Department of Health and sets out the actions required by trusts when someone in their care dies. It also introduces new tools and reporting expectations for all trusts from 1 April 2017.

This week, representatives from national healthcare organisations, NHS trusts and many of the families and carers that were involved in our review came together at the 'Learning from deaths' conference in London to discuss the first edition of this guidance. Their discussions will inform an updated version that will be published on the NQB website.

Throughout the year, there will also be specific responses to the range of issues we highlighted for people with mental health needs or a learning disability, new guidance for families and carers on what to expect from the investigation process and staff training programmes.

Further updates on this programme of work will be made available on the NQB website in April.

Alongside this, CQC will be strengthening the way that we assess the how trusts learn from deaths to include closer review of how trusts identify patients who have died and decide which reviews or investigations are needed. This work is part of the changes we are making to our future inspection approach.

Professor Sir Mike Richards, CQC's Chief Inspector of Hospitals, said: "We know that the quality of investigations is not good enough and that families and carers are not always properly involved in the investigations process or treated with the respect they deserve, so I am glad that action to address this has become a national priority.

"We are continuing to work closely with NHS Improvement, NHS England, families and carers and NHS trusts to ensure the learning from our review, and particularly the importance of involving families and carers in developing solutions, is shared and helps to support the delivery of this work."

The families and carers that contributed to CQC's review will be contacted with further information about how they can continue to be involved in the wider programme of work being taken forward by the NQB.