The National Quality Board published national guidance on learning from deaths: A framework for NHS Trust and NHS Foundation Trusts on identifying, reporting, investigating and learning from deaths in care.
The First Edition was released in March 2017. One of the regulations set out in this guidance states that “Each Trust should have a policy in place that sets out how it responds to the deaths of patients who die under their management and care.”
Learning from deaths is important to our trust as it exemplifies the trust’s ethos of putting patients, families and carers at the centre of everything we do.
The trust board has received detailed information about statistical measures of hospital mortality for many years and since 2013 from the centralised case record review process.
This has helped emphasise the importance of the work carried out in this the trust in this area, supporting the clinical governance arrangements in place to guide this work. The Board provides visible and effective leadership to ensure the organisation addresses significant issues identified in reviews and investigations.
The trust welcomes and encourages feedback from staff, patients, families and others which raise questions or concerns about the policy and how it is implemented. This can be done by patients and families either through the existing PALS, complaints or other patient experience forums and specifically in this area through the bereavement service and the developing medical examiner system.
Staff may also use existing staff feedback mechanisms for general concerns but may also specific raise concerns through their relevant professional or organisational routes and may also have direct contact with the medical examiners who contact the staff who cared for a patient who has died.