Care Quality Commission
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
Latest News from
Care Quality Commission
Working with National Voices and the Point of Care Foundation on Regulators’ Pioneer Fund project21/02/2024 12:05:00
In September 2023, the Regulators’ Pioneer Fund awarded us a grant of £635,394.
National survey shows some improvement in maternity experiences, but help not always available when needed09/02/2024 16:05:00
Findings from a survey of more than 25,500 women and people who used NHS maternity services in 2023 indicate some aspects of care have improved in the past year, but many maternity care experiences are still less positive than they were five years ago.
Secretary of State commissions CQC to conduct rapid review into Nottingham mental health services02/02/2024 10:25:00
Victoria Atkins MP, Secretary of State for Health and Social Care, has commissioned us to conduct a special review into Nottinghamshire Healthcare NHS Foundation Trust under Section 48 of the Health and Social Care Act 2008.
Update on implementing our local authority assessments: January 202430/01/2024 14:20:00
In December, we published our updated guidance for local authorities ahead of starting our local authority assessments.
Government orders NHS trust review following Nottingham killings29/01/2024 13:12:00
Health and Social Care Secretary Victoria Atkins has ordered a special review into Nottinghamshire Healthcare Foundation Trust which treated Valdo Calocane.
Our new assessment approach: update January 202410/01/2024 14:10:00
We are continuing to roll out our new framework to assess providers region by region.
Consultation on our guidance on visiting in care homes, hospitals and hospices10/01/2024 09:20:00
CQC are consulting on their proposed guidance to help providers and other stakeholders understand and meet the new fundamental standard on visiting and accompanying in care homes, hospitals, and hospices and their roles and responsibilities under it.
Guidance on the management of alcohol in care settings14/12/2023 16:05:00
As part of our commitment to person-centric care, we have worked with the University of Bedfordshire to produce guidance for care home managers and members of the public on the availability and management of alcohol in care homes.