The Mazars' report should cause all care provider organisations to reflect and review their incident reporting and investigation processes and quality governance and assurance frameworks. Today's focus may be on the organisation at the centre of the concerns but the value of the report is in its wider learning about the reporting and review of unexpected deaths.
The report makes recommendations for learning for providers, commissioners and the NHS as a system. For providers there is a focus on:
Culture: The need for Board leadership and oversight to ensure staff at all levels recognise the need for timely, high quality investigation, involvement of families and demonstrate learning;
Assurance: a rigorous assurance framework should be in place to ensure prompt reporting and high quality investigation of incidents and adherence to policy and guidance.
Learning: use of thematic reviews with follow-up, evaluation and demonstration of lessons learned;
Training: both in investigations and co-morbidities, particularly physical health;
Involvement: engaging families better in investigations and ensuring bereavement support is distinct.