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Your spotlight on health and social care services


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Help improve how the NHS learns from unexpected deaths


When someone dies unexpectedly while under NHS care, it is important that the correct processes are in place to find out why. The Care Quality Commission is looking at this issue and wants to hear your views.

The Care Quality Commission is looking at how NHS acute, community healthcare and mental health trusts investigate deaths and learn from them.

People can die for a variety of reasons while under NHS care. Not all deaths require an investigation and just because someone dies it does not mean that the quality of services is poor. What is important though is that when someone does die unexpectedly this is identified so that the correct processes can be followed. 

Why are investigations important?

Investigations are important so that NHS Trusts can:

  • learn from any problems that need to be fixed to stop future deaths and improve services;
  • find out if there are any other concerns in the care leading up to death;
  • provide information to the Coroner if needed;
  • work with families to understand what happened and answer questions.

Concerns raised about deaths on mental health ward

In 2014, we raised concerns with the Chief Executive of NHS England about the absence of an external investigation into four deaths at the same low secure mental health service. Find out more

Why is a review taking place?

In December 2015, the Mazars report, looked at the deaths of people using mental health or disabilities services run by the Southern Health NHS Foundation Trust and identified a number of failings. This included that there was no effective way of reporting, investigating and learning from deaths.

The Care Quality Commission is now looking at how NHS Trusts are investigating deaths across the country to see if similar problems exist, and if opportunities to prevent deaths have been missed. In particular, they are looking at how trusts investigate and learn from deaths of people using learning disability or mental health services.

Do you have an experience you would like to share?

If you've been affected by the way an NHS trust has reviewed or investigated a death, your feedback could play a valuable part in the review.

By highlighting what is working well or things that need to change for the better, your views will inform the review directly, which in turn should will help the way the NHS investigates and learns from deaths in the future.