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Learning from deaths: Does the CQC think you are doing enough?

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By Corinne Slingo & Tracey Longfield


Published 21 March 2019


How have NHS Trusts been doing with improving learning from patient deaths?

The CQC sheds some light on this in its recently published report - “Learning from deaths: A review of the first year of NHS Trusts implementing the national guidance”.

Perhaps unsurprisingly, the report paints a mixed picture, with Trusts being at different stages of implementing the guidance and some finding it more challenging than others to bring about the changes required. By looking at the factors most likely to support or limit progress on learning from deaths, the report seeks to encourage Trusts to speed up the pace of improvement.

With learning from deaths clearly a key focus area for the CQC, it will be vital for every organisation to get this right in order to maintain and/or improve its well-led rating.

We look at the report’s key findings and what happens next.


What are the learning from deaths requirements?

It is now 2 years since the National Quality Board published its ‘National Guidance on Learning from Deaths’ with the aim of bringing in a more standardised approach to how NHS Trusts report, review and learn from patient deaths.

By way of recap, the requirements include:

  • Robust governance around learning from deaths, including appointing directors to provide specific oversight;

  • Establishing a process for identifying deaths where there were problems with the care, via a system of ‘case record reviews’;

  • Quarterly reporting of numbers of deaths, numbers of case record reviews and numbers of deaths assessed as being related to problems with the care;

  • Prioritising meaningful engagement at all stages with the family/carers of patients who have died.

Whilst the guidance itself is addressed to NHS Trusts, the broad principles around good governance and properly involving family/carers in the learning from deaths process are equally applicable to independent sector providers.


What to take from the CQC’s report?

Since September 2017, the CQC has been assessing how NHS Trusts have been implementing this learning from deaths guidance as part of its ‘well-led’ inspections.

The central message is that Trusts need to focus on what the CQC has found to be the key drivers to improving learning from deaths in order to build on their progress so far. Whilst acknowledging that cultural change takes time, the CQC feels that the current pace of change is not fast enough.

Reflecting the ‘enablers’ for improvement as identified by the CQC in its report, Trusts may wish to consider:

  • How well does the Trust meaningfully engage families/carers in the process?
    The need to involve and support family/carers right from the start is one of the CQC’s main areas of focus, and also one of the areas which some Trusts are still finding the most challenging. Fears about adding to families’ distress, lack of staff training/experience in this and concerns about career repercussions are all factors identified by the CQC as holding back progress here.

    The CQC is essentially wanting to see more done to consistently involve family/carers throughout the process. Examples of good practice highlighted in the report include establishing a clear process for how families/carers will be contacted/supported/involved in every case, introducing dedicated family liaison officers and organising specialist bereavement training for the Trust’s learning from deaths team.

  • To what extent does the Board prioritise and lead on learning from deaths?
    Another key factor identified by the CQC in driving progress on learning from deaths is the need for clear, consistent leadership at a senior level, with effective challenge and oversight from non-executives.

    Indeed, strong Board support providing strategic leadership and encouragement generally is seen as a key influencer here in relation to learning from deaths.

  • Could the Trust’s culture be more open?  
    The CQC has also highlighted that having a positive, open and learning culture which encourages staff and people who use services to speak out is vital to maximising learning from patient deaths.

    This means that organisations with an existing open culture have found implementing the learning from deaths agenda less challenging than those which have tended towards a more inward-looking, fearful culture.

  • Do staff have the resources they need for this?
    Ensuring that staff have the time, training and support they need to carry out high-quality reviews and investigations is flagged by the CQC as another crucial factor here - e.g. giving staff protected time for undertaking reviews and training.

  • Could more be done to work positively with other organisations on this?
    Finally, the CQC’s report underlines the importance of developing positive working relationships with other organisations also involved in providing care to the person who has died, so as to enable sharing of information and learning. The report does however acknowledge that there can be challenges here - e.g. concerns about sharing patient data across different services and difficulties encountered by some Trusts in engaging others (e.g. primary care) in joint reviews.

What next?

As well as looking at what Trusts need to do themselves to accelerate progress on this, the CQC’s report also flags some areas for development by the national learning from deaths programme itself, including:

  • In light of feedback that the national guidance is too ‘acute focused’, could it be developed to give more of a steer to mental health and community services about which deaths outside hospital should be subject to review;

  • There needs to be a system-wide approach to learning from deaths, with more clarity about which organisations should take the lead on deaths outside hospital and encouraging information sharing across NHS providers (including GPs);

  • There also needs to be a single set of consistent guidance for staff on how to carry out robust reviews of patient deaths, agreed across national bodies.

We will have to wait and see whether these points are reflected in changes to the national guidance going forward.

For now though, the CQC will be certainly be expecting to see Trusts building on the progress they have made with learning from deaths so far by focusing on the drivers for improvement as highlighted in its report.


How we can help

Our national team of healthcare regulatory lawyers has extensive experience of supporting and advising health and social care providers on a wide range of matters relating to patient deaths, including:

  • CQC 'well-led' assessment support, including advice/mock interviews for Board members and senior managers relating to the learning from deaths agenda;

  • Advice on Duty of Candour requirements;

  • Reviewing draft serious incident investigation reports/actions plans;

  • Advice on independent investigations - e.g. input on scope and draft findings;

  • Training for serious incident investigators;

  • Representation and support in relation to further investigations which may be linked to patient deaths, including inquests and CQC or police investigations.