The CQC has reviewed the progress made by the NHS since the 'Learning from Deaths' guidance, which introduced new requirements to scrutinise each death and publish the number of deaths which were 'due to problems in care'.

The CQC concludes in their March 2019 report 'Learning from deaths: A review of the first year of NHS trusts implementing the national guidance' that more needs to be done to create an open, learning culture. This echoes the CQC review of Never Events, which found that "the culture of an organisation could affect how well an organisation was able to implement safety guidance". It is also recognised that the guidance is better suited to acute trusts than mental health or community trusts, in part because of the higher number of deaths in the community which are at the end of life.


The CQC report includes positive case studies, and identifies five themes which are said to affect the successful adoption of the Learning from Deaths guidance:

1. Practically enabling engagement with families

Unsurprisingly, some staff reported to the CQC that they were scared of engaging with families after a death. The CQC advises skills training for staff, with education to allay concerns about the risks to their registration and a supportive culture when mistakes happen. A Trust with three 'family liaison leads' is praised, along with Trusts that have a clear policy and structure for continued engagement with families throughout investigations. The CQC refers to specific guidance on working with bereaved families.

2. Obvious and senior leadership in relation to Learning from Deaths

One Trust (rated outstanding for leadership) is praised for naming the medical director as the operational lead and holds weekly executive meetings to review all deaths reported. Another Trust appointed a public health consultant, who was given the time and resources to lead on the implementation. The CQC recommend that this is a top priority, and that high turnover of staff reduce the ability of the organisation to learn from deaths.

3. A learning culture which encourages staff to speak up about safety issues

Positive cultural factors were:

  • staff at all levels feeling able to speak up
  • a working environment that feels like "a collaborative team"
  • strong patient focus
  • engagement of medical staff (particularly consultants)
  • a desire to learn as a central value of the organisation
  • a reporting system that allows for improvement suggestions
  • the recognition / praising of timely investigations

4. Staff with time and resources

The CQC praise allowing time away from clinical commitments to take responsibility, protected time for reviews and training and support from board and clinical commissioning groups (CCGs) for resources such as a medical examiner or mortality technician.

5. Positive working relationships with other organisations

Staff are concerned about sharing data. Poor relationships or a lack of knowledge of which other organisations were involved in the care prevents learning. The CQC praises efforts to build relationships with primary care and utilising CCGs to enable co-operation.

The case studies published at the end of the report are a useful indicator of what the CQC considers to be good practice, for an organisation to demonstrate a commitment to learning from deaths. There is also a significant recognition; that some staff are scared to engage with families. To really see a change in this aspect of engagement, all of the staff need;

  1. Skills training, to engage confidently with bereaved families and carers,
  2. To be supported in a learning culture, where 'human factors' are investigated fully rather than 'individual mistakes', and
  3. Education and a written resource about the legal aspects of candour, including honest information about the risks to their job and professional registration.

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