CQC Review into How the NHS Investigate and Learns From Deaths

The CQC is looking at how NHS acute, community healthcare and mental health trusts investigate deaths and learn from their investigations. Assessing whether opportunities to prevent deaths are being missed.

Following the publication of the Mazars report – which looked at the deaths of people using mental health or learning disability services run by Southern Health Foundation Trust, the government asked the CQC to look at how NHS trusts across the country investigate deaths to find out whether similar problems can be found elsewhere.

The review will look particularly closely at how trusts investigate and learn from deaths of people using learning disability or mental health services.

Following the review the CQC will publish a report setting out their findings and making recommendations. Ensuring that there is clear guidance for NHS trusts outlining expected good practice in identifying, reporting and investigating deaths and embedding learning to improve care. Trusts will then be measured against these standards during inspections.

The Review Process

The CQC’s report will be informed by a number of different activities:

• A national survey of NHS trusts (which will be sent out this month) and discussions with trusts through the CQC’s online portal for service providers.
• Work with bereaved families.
• Work with an expert advisory group made up of a range of people and organisations, including charities, campaigners and government bodies.
• Work with partner organisations, including NHS England, NHS Improvement and the Department of Health.
• Visits to a sample of acute, community healthcare and mental health NHS trusts to gather evidence over the summer.

The final report will be published in December 2016.