CQC 13 December 2016
- An examination of the processes and systems acute, community and mental health trusts use to identify, investigate and learn from the deaths was not able to identify any trust that demonstrated good practice across all aspects of identifying, reviewing and investigating deaths, and ensuring that learning is implemented.
- The report focused on five key areas:
- Involvement of families and cares
- Identification and reporting
- Decision to review or investigate - use of the Serious Incident Framework
- Reviews and investigations
- Governance and learning
- The CQC set out a number of recommendations.
- Jeremy Hunt has announced that he accepts all of the CQC recommendations and has announced that as of 31 March 2017 NHS trusts will be obliged to publish information on deaths that were potentially avoidable and serious incidents - see CQC review of deaths of NHS patients
