Our review of how NHS trusts investigate and learn from deaths

29 Jul 2016 01:20 PM

We're looking at how NHS acute, community healthcare and mental health trusts investigate deaths and learn from their investigations. We also want to assess whether opportunities to prevent deaths have been missed.

Your feedback

If you've been affected by the way an NHS trust has reviewed or investigated a death, your feedback could play a valuable part in our review. Whether you feel the trust's approach to reviewing or carrying out the investigation was good or bad, we'd like to hear from you.

Your feedback will directly inform our review, which in turn should improve the way the NHS investigates, and learns from, deaths in the future.

We can't make complaints for you or take them up on your behalf. That may seem confusing but it's because we don't have powers to investigate or resolve them. The only exception to this is for people whose rights are restricted under the Mental Health Act. In certain circumstances, we can act on behalf of someone whose rights have been restricted under the act.

However, your feedback is vital to helping us understand how reviews and investigations are handled, the impact this has on people and how you think we can learn from your experience and what may need to change in future.

Tell us about your experience now
 

Why we're carrying out this review

The Mazars report – which looked at the deaths of people using mental health or learning disability services run by Southern Health Foundation Trust – set out a number of failings. These included that the trust had no effective overall way of reporting, investigating and learning from deaths.

The government has asked us to look at how NHS trusts across the country investigate deaths to find out whether similar problems can be found elsewhere. We will look particularly closely at how trusts investigate and learn from deaths of people using learning disability or mental health services.

What we're doing

To carry out this work, we will:

• listen to families and invite comments and discussion through our public online community
• work with an expert advisory group made up of a range of people and organisations, including charities, campaigners and government bodies
• work with our partners, including NHS England, NHS Improvement and the Department of Health
• carry out a national survey with all NHS trusts
• talk to NHS trusts through our online community for providers
• visit a sample of acute, community healthcare and mental health NHS trusts to gather evidence.

We follow a consistent process when we carry out reviews. Read about our review process.

Where we are now

We are now gathering evidence for the review. We worked with stakeholders – including our Expert Advisory Group, online communities and providers – to:

• identify a selection of 12 sites across the country for our visits
• develop our assessment framework – this tells our inspectors what to look for and what questions to ask. The assessment framework is available to read on our public online community and provider online community
• design the survey for NHS trusts, which we sent out early in July.

We are now:

• carrying out our site visits, which will continue during August
• beginning to analyse the results of our survey of NHS trusts
• asking groups and organisations that represent the public to use our online form to give us information to help us understand more about practice at a local level.

What we aim to achieve

• We'll publish a report setting out our findings and recommendations.
• We'll work with national partners to make sure there is clear guidance for NHS trusts that describes the expected good practice in identifying, reporting and investigating deaths and embedding learning to improve care.
• We'll use the findings in the report to improve the way we monitor and regulate services.

We aim to publish our findings in December 2016.