Learning from deaths

Published: 18 March 2019 Page last updated: 19 March 2019

A review of the first year of NHS trusts implementing the national guidance

In 2016, we looked into how acute, community and mental health trusts investigate and learn from deaths. This resulted in new national guidance. Here we report on our assessments of how NHS trusts are putting it into practice.


We set out the findings of our original review in December 2016, when we published Learning, candour and accountability.

Since September 2017, we have been assessing NHS trusts' implementation of national guidance on learning from deaths. This forms part of our new well-led inspections. Now that we have completed most of these inspections, we are setting out what we have found.

What we did

We carried out qualitative analysis of interviews and focus groups with inspection staff and advisors. They were all involved in well-led inspections between September 2017 and June 2018.

We also carried out a case study analysis of three trusts that we rated outstanding for well-led between September 2017 and June 2018.

What we found

We have seen variation in how trusts are implementing the new guidance. While awareness of the guidance is high, some trusts are finding it more difficult than others to make the changes they need.

There is some, limited evidence that suggests the guidance is better suited to acute trusts than mental health or community trusts.

Factors that enable good practice

Our findings suggest the factors that help trusts to put the guidance into practice are:

  • values and behaviours that encourage engagement with families and carers
  • clear and consistent leadership
  • a positive, open and learning culture
  • staff with resources, training and support
  • positive working relationships with other organisations