A review was recently published that assessed how well NHS trusts are implementing the learning from deaths guidance introduced following the Care Quality Commission (CQC) report Learning, candour and accountability.

The guidance recommended that NHS trusts have processes for identifying deaths that have resulted from problems with care; that directors be appointed to take responsibility for their progress; that there is a clear policy for engaging families and carers; that there must be appropriate staff training; and, lastly, that information regarding such deaths should be published on a quarterly basis.

Since September 2017, the CQC has been assessing how well NHS trusts have been implementing this guidance. Their recent review is based on a qualitative analysis of interviews with focus groups and inspection staff, plus a case study analysis of three trusts.

The CQC concluded that the degree to which the trusts are carrying out the guidance is variable. Trust feedback suggests the guidance is better suited to acute trusts rather than mental health or community trusts.

Responses include suggestions that, in the community, there are a high number of deaths where persons are reaching the end of their lives in the normal course of events. In this situation, community-based services often have difficulty learning about deaths that occur in the community.

The CQC found the following factors facilitated the guidance:

  • Values and behaviours that encourage engagement with families
  • Good leadership
  • An open culture
  • Adequate staff resources
  • Positive working relationships

Engagement with families/carers

CQC analysis showed that there is variation in how well trusts engage with families/carers. Some trusts provided ad hoc engagement only after a serious incident or complaint. Inspections staff noted that staff could be fearful of engagement due to lack of skills or confidence, not wanting to distress the family further or concerns regarding professional repercussions.

Several trusts have good procedures in place, examples of which include clear processes for initially contacting families; sympathetic techniques for delivering condolences and support; and involving families or carers in the investigations. Within the best-performing trusts, explanations are given and, where appropriate, an apology. There is communication through a single point of contact, with some trusts conveying condolences or delivering on their duty of candour at first point of contact. Some families are visited at a place of their choosing and are provided with open and honest correspondence. Other trusts have good links with external bodies, including local authorities, clinical commissioning groups, other trusts and the coroner. Bereavement signposting and pastoral care are also offered in the best cases.


The CQC identified that the key to implementing the guidance is to have ‘a specific person at a reasonably high level in the trust… driving the work forwards’.

Open learning culture

Responses confirmed that existing culture can be a key factor in a trust’s ability to implement the guidance. The CQC concluded that, where there is an open, transparent, no blame culture, focused on learning, this is very different from an inward-looking, fearful culture, which can manifest in defensiveness and blame.


Having resources was an important factor in delivering implementation of the guidance. Feedback showed that some trusts were not in an equally good position to allocate resources. Some trusts were freeing up people from clinical commitments to take responsibility - time was protected for reviews and training and there was support for resources such as a medical examiner.

Engagement with partner organisations

Evidence showed that the quality of existing relationships between organisations could affect how well trusts are working with partners. Lack of incentive or support can be a barrier to collaborative investigation into deaths. Difficulties in sharing information can also be a barrier. Inspection staff felt that CCGs could do more. Concerns regarding data protection were also raised, centring on a lack of understanding of the rules and regulations for sharing information.

Three case studies

The first case study focused on West Suffolk NHS Foundation Trust. The inspection staff felt that the trust had done well implementing the guidance. A public health consultant had been appointed with dedicated time and resources. The trust had existing processes; a quality improvement framework had been introduced; and there was a good approach to involving the family/carers.

The second trust studied was Greater Manchester Mental Health NHS Foundation Trust. The Trust submitted that learning from deaths was of limited use to them, explaining that ‘there can be [a] very different view taken if someone has died of a surgical procedure, which can be measurable, to someone who has taken their own life in a community setting’.

They were found to have good governance and procedures already in place so they did not need to make significant changes. Resourcing was a challenge and the trust was using the reports to assist with quality improvement. One of the trust’s strength was how they engaged with families – they were using a person centred approach.

The third case study was Norfolk Community Health and Care NHS Trust, which was reviewing all inpatient deaths and making changes to the existing processes. They thought that the guidance was ‘acute focused,’ and the executive board had driven developments in processes for learning from deaths. They stated that sharing lessons with other trusts had been helpful. The Trust was expanding its policy to ensure that the correct deaths were identified for review. Further work was being completed to improve family engagement.

Next steps and recommendations

The CQC concluded that their findings highlighted many of the same issues as identified in the original report. They stated that there is a need for NHS trusts to:

  • Encourage values and behaviours for engagement with families/carers
  • Have clear, consistent leadership
  • Have a positive, open learning culture
  • Provide time and support to staff
  • Facilitate positive work relationships

They concluded that ‘the existing culture of an organisation can be a key factor in trust’s implementation of guidance and could be preventing trusts from making the progress needed. To be able to learn from serious incidents in the NHS, there needs to be a culture where staff, patients and leaders all feel able to speak up and work collaboratively and learn.’

The CQC submit that, where trusts do not have these characteristics, they need to start investing in them, taking a long-term view.

The programme now needs to align work with related policy initiatives; develop system-wide learning; assess the progress made on investigating deaths of those with mental health issues or learning disabilities; agree national guidance from bodies such as NHS Improvement and Healthcare Safety Investigation Branch; further analysis and monitoring; and further support and training for CQC inspection.

View the report