BBC News. Shropshire baby and mother maternity deaths review widened. 2018. (accessed 2 April 2019)

BBC News. Shropshire baby deaths: Families could pull out of inquiry. 2019. https://bbc. in/2FRdQRl (accessed 2 April 2019)

Care Quality Commission. Learning, candour and accountability: a review of the way NHS trusts review and investigate the deaths of patients in England. 2016. (accessed 2 April 2019)

Care Quality Commission. Learning from deaths: a review of the first year of NHS trusts implementing the national guidance. 2019. (accessed 2 April 2019)

Department of Health. An organisation with a memory: report of an expert group on learning from adverse events in the NHS chaired by the Chief Medical Officer. 2000. (accessed 2 April 2019)

Gosport Independent Panel. Gosport War Memorial Hospital: the report of the Gosport Independent Panel. HC 1084. 2018. (accessed 2 April 2019)

The report of the Morecambe Bay investigation. 2015. (accessed 2 April 2019)

Report of the Liverpool Community Health independent review. 2018. (accessed 2 April 2019)

Improving NHS trusts' learning from patient deaths

11 April 2019
Volume 28 · Issue 7


John Tingle discusses a new CQC report that reviews the first year of NHS trusts implementing national guidance on learning from deaths, in the context of some other associated reports

When we look at government and health regulatory publications over the last 20 years or so, a stark picture begins to emerge. The publications all seem to speak in similar tones about the same patient safety, health quality problems and challenges. Common solutions are regularly advanced but the same problems stubbornly remain.

In 2000 the seminal document on patient safety and health quality, An Organisation With a Memory, was published (Department of Health, 2000). This publication laid the foundations for patient safety policy development in the NHS and identified several key problems that are still with us today:

‘We believe that, if the NHS is successfully to modernise its approach to learning from failure, there are four key areas that must be addressed. In summary, the NHS needs to develop:

This report also discussed the need for a more open NHS culture when errors are reported. Publications in 2019 are repeating the same messages and calls. The Care Quality Commission (CQC) has recently published a report on progress made by NHS trusts in the first year of implementing national guidance on learning from deaths (CQC, 2019). This shows marked variation in how trusts are implementing the new guidance, with some clearly finding it difficult.

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