Unexpected Deaths Investigations: Learning from incidents - DAC Beachcroft

Unexpected Deaths Investigations: Learning from incidents's Tags

Tags related to this article

Unexpected Deaths Investigations: Learning from incidents

Published 1 January 2016

The Mazars' report should cause all care provider organisations to reflect and review their incident reporting and investigation processes, and quality governance and assurance frameworks. Today's focus may be on the organisation at the centre of the concerns, but the value of the report is in its wider learning about the reporting and review of unexpected deaths.

The report makes recommendations for learning for providers, commissioners and the NHS as a system. For providers there is a focus on:

Culture

The need for Board leadership and oversight to ensure staff at all levels recognise the need for timely, high quality investigation, involvement of families and demonstrate learning.

Assurance

A rigorous assurance framework should be in place to ensure prompt reporting and high quality investigation of incidents and adherence to policy and guidance.

Learning

Use of thematic reviews with follow-up, evaluation and demonstration of lessons learned.

Training 

Both in investigations and co-morbidities, particularly physical health.

Involvement

Engaging families better in investigations and ensuring bereavement support is distinct.

< Back to articles