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Published 21 marzo 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.
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:
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.
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:
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:
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.
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:
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