Care Quality Commission
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CQC's review of how NHS trusts investigate and learn from deaths

CQC are 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.

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

The review is in the design stage. We've begun talking to stakeholders through:

  • our online communities
  • our expert advisory group, which held its first meeting on 20 May.

Our next steps include:

  • sending a survey to all NHS trusts in June
  • carrying out site visits over the summer.

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.

Find out more

Read the Mazars report

Read Sir Mike Richards' statement about the review

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