Implementing the national learning from deaths guidance

June 25, 2020 Polly Kirk

Around 50% of all deaths occur in hospital and while many of these are inevitable, it is estimated that between three and five percent of deaths in acute hospitals in England could be avoided (read more). Over the past few years, a number of significant reports have highlighted major weaknesses in the way healthcare organisations investigate and learn from instances of avoidable harm and death. 

In 2016, the Care Quality Commission (CQC) published a report which looked at how NHS trusts review and investigate the deaths of patients in England (read full report here). The findings of this report highlighted that families and carers often have a poor experience of investigations, that the quality of investigations is variable and inconsistent and crucially, that these issues act as a barrier to identifying opportunities for learning.

At the time the CQC report was published, the CQC’s former Chief Inspector of Hospitals, Sir Mike Richards, said “The extent of the problems is more than I expected. The whole system [of investigating deaths] needs an overhaul at national level and local level.”

In response, the government outlined a series of new requirements that all NHS trusts and foundation trusts are now required to meet. Read more about these requirements. The requirements include:

  • Collecting specified information on serious incidents and deaths that were potentially avoidable and consider what lessons need to be learned on a regular basis.
  • Publishing information quarterly, in accordance with new regulations, so that local patients and the public can see where progress is being made.
  • Publishing evidence of learning and action‎ that is happening in response.
  • Identifying a board-level leader as patient safety director to take responsibility for this agenda and ensure it is prioritised and resourced within their organisation.
  • Following a standardised national framework for identifying potentially avoidable deaths, reviewing the care provided and learning from mistakes.

In March 2017, new detailed national guidance about the new Learning from Deaths requirements produced by the National Quality Board (NQB), was published by NHS England. Read full report here.

The guidance stipulates a number of specific requirements all trusts must meet. These include:

Case note review methodology
Every NHS trust is now required to produce a new policy document detailing its approach to responding and learning from deaths of patients who die under its management and care. This must include details of the approach and methodology to undertaking case record reviews, including for mental health trusts, deaths of people with learning disabilities and for neonatal and maternal deaths. The guidance is clear that bereaved families should be involved in the review process and fully supported and engaged with throughout.

Publication of data
Trusts are now required to collect and publish detailed information on deaths on a quarterly basis through a board paper and an agenda item at the public Board meeting.

These changes make the NHS the first healthcare system in the world to commit to reporting and publishing information on the number of avoidable deaths in its hospitals and the work that is being done at a local level to learn from those deaths.

The government has confirmed that adherence to these guidelines will be closely scrutinised by the CQC as part of all future inspection activity. More importantly though, these changes reflect a recognition that we need to learn from all deaths in healthcare, that it’s no longer acceptable to view any death as “one of those things” and that every death requires an open and honest review so that opportunities to learn and improve care for the future aren’t missed. These changes will help ensure healthcare organisations locally are able to take a wider view of any trends and take a more proactive approach to reducing avoidable harm.

How can RLDatix help? 

RLDatix has developed a Mortality Review module specifically designed to help learning from deaths by capturing, reviewing and reporting all mortalities in one system:

  • The module provides a structured framework: Organisations can report and capture mortality data and document decisions on the level of review/investigation required. The system is fully configurable to support different review methodologies, for example for patients with learning disability, mental health needs, infant or child deaths and stillbirth or maternal deaths.
  • The module is part of the DatixCloudIQ platform: Providing structured tools to assist with investigation processes. An Investigations module supports the engagement of families throughout the entire process - a key requirement of the new guidance.
  • The module allows recording of actions: The Investigations module also makes it easy to record the actions taken in response to mortality reviews in order to demonstrate the lessons that have been learned.
  • Mortality Review offers improved learning: The module has been designed to improve learning from deaths by capturing data, simplifying workflows and highlighting learning points. The module incorporates a two-stage adaptable process, providing the structure required to carry out a formal review or evidence when a review is not required.
  • Quick production of reports and dashboards: Making it easy to view graphic and statistical information and export data to other systems, as required, for further analysis alongside broader data sources within the organisation. This makes it easy for clinicians to review mortality records, ask screening questions, and analyse and learn from any deficiencies in the care of patients. 
  • The data collated is stored centrally and any updates occur in real time: Utilising the reporting functions and dashboards can allow organisations to provide key data to all relevant staff members that need to know. Information on all deaths can be easily displayed on dashboards and queries can be saved. This allows organisations to more efficiently gather important information and easily export it and report to relevant authorities.

RLDatix has created a system designed to meet all the requirements of the new Learning from Deaths guidance and is configurable to the exact needs of individual organisations. It allows organisations to conduct mortality reviews locally, detail actions to move forward and identify lessons learned, ensuring you are compliant with all of the CQC requirements.

The module is powerful on its own, but it also operates within the wider data collection capabilities of the DatixCloudIQ platform. Users can delve into a greater level of detail with a link to the Investigations module, which provides tools into root cause analysis for adverse events and highlights recommendations for areas of improvement. Evidence of learning and improvement are available all within the one DatixCloudIQ system.


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