Learning from deaths
In 2013 a boy called Connor Sparrowhawk died. This led to a report called the Mazars Report in 2015. The report found serious problems with how Southern Health NHS Trust reviewed and managed deaths between 2011 and 2015.
After this, the Care Quality Commission (CQC) published a report called ‘Learning, Candour and Accountability’. It showed that some NHS organisations were not giving enough attention to learning from deaths. This meant chances to improve care were being missed.
The CQC made recommendations to make the process the same across the NHS. In 2017, the National Quality Board published the first ‘National Guidance on Learning from Deaths’. This gave NHS trusts a clear framework for identifying, reporting, investigating, and learning from deaths. One key rule was that every trust must publish a policy on how it responds to and learns from patient deaths.
In 2019, guidance was published on the new role of Medical Examiners. They check death certificates to make sure they are correct. They also talk to families, giving them support and a chance to raise concerns. This helps make the time after death easier and makes sure learning happens both for the trust and the family.
At STSFT, we also have a Mortality Review Group.
What is the Mortality Review Group?
Our Mortality Review Group makes sure we have systems to monitor and report on deaths. It helps the Board understand what different death measures mean and why they matter. The group also shares what it learns from reviews so local care is safe and effective.
What does the group do?
- Looks at national rules on death reviews and make local systems stronger
- Helps shape policy and practice so reviews lead to better patient care
- Assures the Board that review processes work well and staff know their role
- Makes sure any differences in death rates are dealt with in the right way
- Reports regularly on death reviews to the Trust and to the public
