Learning from deaths

For us, learning from deaths is a BHAG – those big hairy audacious goals which form the basis of all we deliver. This shows how seriously we take this; we are not at all complacent in how far we too have to travel. For the CQC, their focus comes from their 2016 review ‘Learning, candour and accountability’ and this is rightly now getting proper national attention.

Their Chief Inspector of Hospitals, Professor Ted Baker said that “there needs to be continued support from the centre, including support for behaviours that encourage more openness and learning across the NHS”. He is right that a trust’s culture and the staff’s ability to speak out and speak freely is crucial. Failure to fully embrace an open, learning culture may be holding organisations back. This chimes really powerfully for me and I am sure it will for many of you. We have a Just and Learning Culture which really does meet its front line in how each of us as colleagues, managers and as a Trust, deals with this most serious of issues.

I am pleased that our regulators have so clearly made the connection between learning from deaths and a more open culture. As we have said all along, we are not creating an uncritically tolerant culture – these are exceptionally series issues – but neither can we have one which goes straight to blame without asking “what has happened and how can we learn from this?” 

  • The scope for reviewing deaths in the community will have been agreed and implemented by March 2019
  • Scope for reviewing individuals in mental health care will have been reviewed and new standards adopted by March 2019
  • Single action plan for monitoring completion of learning points will be developed and completion of actions monitored by March 2019
  • Four thematic reviews will be conducted per year based on an analysis of mortality figures by March 2019
  • Data from GPs, specifically the cause of death will be used as part of the mortality review process. The process for undertaking pathway reviews will have been developed and implemented in association with partner organisations by March 2019.