In 2016, a national review by the Care Quality Commission (CQC) found that the NHS was missing opportunities to learn from patient deaths and that too many families were not being included or listened to when an investigation happened. A key recommendation from this review was that a national framework be developed, so that NHS Trusts have clarity on the actions required when someone dies in their care.
The National Guidance on Learning from Deaths published by the National Quality Board (NQB) in March 2017, recommended all Trusts to publish a policy on how the organisation responds to and learns from deaths of patients who die under their management and care. The frameworks purpose is to initiate a standardised approach for reporting, investigating and learning from deaths in care.
This policy sets out the Northamptonshire Healthcare NHS Foundation Trust's approach to meeting the National Guidance on Learning from Deaths (NQB 2017) and how they seek to learn from the care provided to patients who die. This policy makes clear the procedure for responding to and learning from patient deaths across the Trust including:
- How the process will respond to the death of an individual.
- Determine the categories and selection of deaths in scope for review.
- How the Trust engages with bereaved families and carers, including how the trust supports them and involves them in investigations.
- How staff affected by the deaths of patients will be supported by the Trust.
- How the Trust learns from deaths to improve and inform clinical practice.
- The themes and issues identified from review and investigation, including examples of good practice.
- How the findings, themes and issues from reviews and investigations will be used to inform and support quality improvement activity; any other actions taken, and progress in implementation.
- How the Trust collects specific information every quarter of those who die, outcomes of reviews of care and publish this information on a quarterly basis to public board meetings.