Learning from deaths

The findings of an “Independent review of deaths of people with a Learning Disability or Mental Health problem in contact with Southern Health NHS Foundation Trust April 2011 – March 2015” undertaken by Mazars (published in December 2015) highlighted a number of concerns within Southern Health NHS Foundation Trust (an NHS Trust covering Hampshire and parts of Oxfordshire) about the oversight, management and review of deaths of people with mental health and learning disabilities.

This ultimately led to the publication, in March 2017, of the National Quality Board’s first edition of “National Guidance on Learning from Deaths – A Framework for NHS Trusts and NHS Foundation Trusts on Identifying, Reporting, Investigating and Learning from Deaths in Care”.  The purpose of this national guidance is to help initiate a standardised approach across the NHS which it is anticipated will evolve as learning in terms of mortality review takes place nationally.

Essex Partnership University NHS Foundation Trust has developed a Mortality Review Policy to deliver the requirements of the national guidance locally. This is available as a downloadable document on this page. The Policy provides a governance framework for reviewing the care provided to people who have died – including the identification, recording, reviewing and investigation of deaths.  The aim of these processes is ultimately to help improve care for all our patients by identifying any problems in care, understanding how and why these occurred and taking meaningful action to implement any learning identified.

The Policy also sets out how the Trust will support people who have been bereaved by a death in the Trust and how families and carers can expect to be involved in any action taken to review and / or investigate a death.

It is anticipated that policy and approaches in this area will continue to evolve and develop over the coming months as we learn from national and local experience of mortality review and learning from deaths.