Signs of progress on learning from deaths – but a more open learning culture is needed across the NHS to drive further improvement

18 March 2019 – CQC

CQC inspections have revealed good progress is being made by some NHS hospital trusts to implement national guidance on learning from deaths. However, the regulator said that a failure to fully embrace an open, learning culture may be holding organisations back from making the required changes at the pace needed.

In a report published on 19.03.2019, CQC reviewed inspectors’ observations from the first year of assessing how well trusts are implementing national guidance introduced to support improved investigations and better family engagement when patients die.

National guidance for trusts to initiate a standardised approach to learning from deaths was published by the National Quality Board (NQB) in March 2017, along with guidance for trusts on working with families in July 2018. Both documents were introduced in response to the findings of CQC’s 2016 thematic review Learning, candour and accountability which made a number of recommendations to help to improve the quality of investigations into patient deaths.


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