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National  Guidance on Learning from 
Deaths 
 
A Framework for NHS Trusts and NHS Foundation Trusts on Identifying, 
Reporting, Investigating and Learning from  Deaths in Care 
 
  
                             
 
                                                                        First edition March 2017 
 
 
 
 
 
 
 
 

 

National  Guidance on Learning from     
Deaths 
 
Contents   
1. Foreword   
 
 
 
 
 
 
 
 
3 
2. Executive Summary   
 
 
 
 
 
 
4 
3. Chapter 1: Mortality Governance 
 
 
 
 
8 
4. Chapter 2: Bereaved Families  and Carers 
 
 
15 
5. Annexes 
o  Anne x A:  Board Leadership 
 
 
 
 
 
 
21 
o  Anne x B:  Non-Executive Directors   
 
 
 
 
 
23 
o  Anne x C:  Responding to Deaths 
 
 
 
 
             
26 
o  Anne x D:  Learning Disabilities 
 
 
 
 
 
 
28 
o  Anne x E:  Mental Health 
 
 
 
 
 
 
 
33 
o  Anne x F:  Children and Young People 
 
 
 
 
 
35 
o  Anne x G:  Maternity   
 
 
 
 
 
 
 
46 
o  Anne x H:  Cross-system Reviews and Investigations 
 
 
 
49 
o  Anne x I:  Roles and Responsibilities of National Bodies and 
Commissioners 
 
 
 
 
 
 
 
 
52 
o  Anne x J:  Structured Judgement Review in Mental Health Trusts   
            54 
o  Anne x K:  National Leads 
 
 
 
 
 
 
 
56 
o  Anne x L:  Background and Links 
 
 
 
 
 
 
57 
 
 
 

 




Foreword 
Following events in Mid Staffordshire, a review of 14 hospitals with the highest mortality noted 
that the focus on aggregate mortality rates was distracting Trust boards “from the very practical 
steps that can be taken to reduce genuinely avoidable deaths in our hospitals”. 
 
This was reinforced by the recent findings of the Care Quality Commission (CQC) report 
Learning, candour and accountability: A review of the way NHS trusts review and investigate the 
deaths of patients in England. It found that learning from deaths was not being given sufficient 
priority in some organisations and consequently valuable opportunities for improvements were 
being missed. The report also pointed out that there is more we can do to engage families and 
carers and to recognise their insights as a vital source of learning. 
 
Understanding and tackling this issue will not be easy, but it is the right thing to do. There will be 
legitimate debates about deciding which deaths to review, how the reviews are conducted, the 
time and team resource required to do it properly, the degree of avoidability and how executive 
teams and boards should use the findings. 
 
This first edition of National Guidance on Learning from Deaths aims to kickstart a national 
endeavour on this front. Its purpose is to help initiate a standardised approach, which will 
evolve as we learn. Following the Learning from Deaths conference on 21st March 2017 we 
will  update this guidance to reflect the collective views of individuals and organisations to 
whom this guidance will apply to ensure that it is helpful. 
                                         
                                                                                                    
  
             
                
                                                                   
Professor Sir Bruce Keogh     Professor Sir Mike Richards     Dr Kathy M cLean   
National Medical Director 
    Chief Inspector of Hospitals         Executive Medical Director 
NHS England  
 
    Care Quality Commission            NHS Improvement 
 
On behalf of the National Quality Board. 
 
 

 

Executive Summary 
Introduction 
1.  For many people death under the care of the NHS is an inevitable outcome and they 
experience excellent care from the NHS  in the months or years leading up to their death.  
However some patients experience poor quality provision resulting from multiple contributory 
factors, which often include poor leadership and system-wide failures. NHS staff work tirelessly 
under increasing pressures to deliver safe, high-quality healthcare.  When mistakes happen, 
providers working with their partners need to do more to understand the causes. The purpose 
of reviews and investigations of deaths which problems in care might have contributed to is to 
learn in order to prevent recurrence. Reviews and investigations are only useful for learning 
purposes if their findings are shared and acted upon.    
 
2.  The following definitions apply for the purposes of this guidance: 
  
(i)  Case record review: The application of a case record/note review to determine 
whether there were any problems in the care provided to the patient who died in order to 
learn from what happened, for example Structured Judgement Review delivered by the 
Royal College of Physicians.  
(ii) Investigation: The act or process of investigating; a systematic analysis of what 
happened, how it happened and why. This draws on evidence, including physical 
evidence, witness accounts, policies, procedures, guidance, good practice and observation 
- in order to identify the problems in care or service delivery that preceded an incident to 
understand how and why it occurred. The process aims to identify what may need to 
change in service provision in order to reduce the risk of future occurrence of similar 
events. 
(iii) Death due to a problem in care: A death that has been clinically assessed using a 
recognised methodology of case record/note review and determined more likely than not to 
have resulted from problems in healthcare and therefore to have been potentially 
avoidable. 
 
Governance and Capability  
3.  Learning from a review of the care provided to patients who die should be integral to a 
provider’s clinical governance and quality improvement work. To fulfil the standards and 
new reporting set out in this guidance for acute, mental health and community NHS 
Trusts and Foundation Trusts, Trusts should ensure their governance arrangements 

 

and processes include, facilitate and give due focus to the review, investigation and 
reporting of deaths, including those deaths that are determined more likely than not to have 
resulted from problems in care.  Trusts should also ensure that they share and act upon any 
learning derived from these processes. The standards expected of Trust boards are set out 
at Annex A including having an existing executive director take responsibility for the 
learning from deaths agenda and an existing non-executive director take responsibility for 
oversight of progress. Guidance for non-executive directors is at Annex B.   
 
4.  Providers should review and, if necessary, enhance skills and training to support this agenda. 
Providers need to ensure that staff reporting deaths have appropriate skills through specialist 
training and protected time under their contracted hours to review and investigate deaths to a 
high standard.  
 
5.  Providers should have a clear policy for engagement with bereaved families and 
carers, including giving them the opportunity to raise questions or share concerns in 
relation to the quality of care received by their loved one. Providers should make it a priority 
to work more closely with bereaved families and carers and ensure that a consistent level of 
timely, meaningful and compassionate support and engagement is delivered and assured at 
every stage, from notification of the death to an investigation report and its lessons learned 
and actions taken. 
 
Improved Data Collection and Reporting 
6.  The following minimum requirements are being introduced to complement providers’ 
current approaches in relation to reporting and reviewing deaths:  
 
A.  POLICY ON  RESPONDING  TO DEATHS 
•  Each Trust should publish an updated policy by September 2017 on how it 
responds to, and learns from, deaths of patients who die under its management 
and care, including: 
 
i. 
How its processes respond to the death of an individual with a learning 
disability (Annex D) or mental health needs (Annex E), an infant or child 
death (Annex F) and a stillbirth or maternal death (Annex G). 
ii. 
The Trust’s approach to undertaking case record reviews. Acute Trusts 
should use an evidence-based methodology for reviewing the quality of care 
provided to those patients who die. The Structured Judgement Review (SJR) 

 

case note methodology is one such approach and a programme to provide 
training in this methodology for acute Trusts will be delivered by the Royal 
College of Physicians over the coming year (the current version of the SJR 
approach is available at https://www.rcplondon.ac.uk/projects/outputs/national-
mortality-case-record-review-nmcrr-programme-resources Other approaches 
also exist, such as those based on the PRISM methodology.  Methods like SJR 
were not developed for mental health and community Trusts but can be used 
as a starting point and adapted by these providers to reflect their individual 
service user and clinical circumstances.  Annex J provides a case study of how 
SJR is being adapted for mental health Trusts. Case record reviews of deaths 
of people with learning disabilities by acute, mental health and community 
Trusts should adopt the methodology developed by the Learning Disabilities 
Mortality Review (LeDeR) programme in those regions where the programme 
is available (details of the programme are available from Annex D). 
iii.  Categories and selection of deaths in scope for case record review: As a 
minimum  and from the outset, Trusts should focus reviews on in-patient deaths 
in line with the criteria specified at paragraph 14(ii). In particular contexts, and 
as these processes become more established, Trusts should include cases of 
people who had been an in-patient but had died within 30 days of leaving 
hospital.  Mental Health Trusts and Community Trusts will want to carefully 
consider which categories of outpatient and/or community patient are within 
scope for review taking a proportionate approach. The rationale for the scope 
selected by Trusts will need to be published and open to scrutiny. 
 
B.  DATA COLLECTION AND  REPORTING 
•  From April 2017, Trusts will be required to collect and publish on a quarterly 
basis specified information on deaths. This should be through a paper and 
an agenda item to a public Board meeting in each quarter to set out the 
Trust’s policy and approach (by the end of Q2) and publication of the data 
and learning points (from Q3 onwards).  This data should include the total 
number of the Trust’s in-patient deaths (including Emergency Department deaths 
for acute Trusts) and those deaths that the Trust has subjected to case record 
review. Of these deaths subjected to review, Trusts will need to provide estimates 
of how many deaths were judged more likely than not to have been due to 
problems in care. The dashboard provided with this guidance shows what data 
needs to be collected and a suggested format for publishing the information, 

 

link to page 1 link to page 7 link to page 7 accompanied by relevant qualitative information and interpretation. 
•  Changes to the Quality Accounts regulations will require that the data 
providers publish be summarised in Quality Accounts from June 2018 
(Annex L), including evidence of learning and action as a result of this information 
and an assessment of the impact of actions that a provider has taken.  
 
Further Developments 
7.  In 2017-18, further developments will include: 
 
•  The Care Quality Commission will strengthen its assessment of providers learning 
from deaths including the management and processes to review and investigate deaths 
and engage families and carers in relation to these processes.  
•  NHS England, led by the Chief Nursing Officer, will develop guidance for bereaved 
families and carers. This will support standards already set for local services within the Duty 
of Candour  and the Serious Incident Frameworkand cover how families should be engaged 
in investigations. Health Education England will review training of doctors and nurses on 
engaging with bereaved families and carers. 
•  Acute Trusts will receive training to use the Royal College of Physicians’ 
Structured Judgement Review case note methodology. Health Education England 
and the Healthcare Safety Investigation Branch (Annex L) will engage with system 
partners, families and carers and staff to understand broader training needs and to 
develop approaches so that NHS staff can undertake good quality investigations of 
deaths. 
•  NHS Digital is assessing how to facilitate the development of provider systems 
and processes so that providers know when a patient dies and information from 
reviews and investigations can be collected in standardised way. 
•  The Department of Health is exploring proposals to improve the way complaints 
involving serious incidents are handled particularly how providers and the wider 
care system may better capture necessary learning from these incidents3. 

 
                                                             
1  Further information is available from: 
http://www.cqc.org.uk/sites/default/files/20141120_doc_fppf_final_nhs_provider_guidance_v1-0.pdf 
2  https://improvement.nhs.uk/resources/serious-incident-framework/ 
3  This follows the Parliamentary and Health Service Ombudsman’s report Learning from Mistakes (July 
2016) and the Public Administration and Constitutional Affairs Committee hearings on this report.  
 

 

link to page 7 Chapter 1 - Mortality  Governance 
Context 
8.  In December 2016, the Care Quality Commission (CQC) published its review Learning, 
candour and accountability: A review of the way NHS trusts review and investigate the 
deaths of patients in England. The CQC found that none of the Trusts they contacted were 
able to demonstrate best practice across every aspect of identifying, reviewing and 
investigating deaths and ensuring that learning is implemented.  
 
9.  The Secretary of State for Health accepted the report’s recommendations and in a 
Parliamentary statementmade a range of commitments to improve how Trusts learn from 
reviewing the care provided to patients who die. This includes regular publication of 
specified information on deaths, including those that are assessed as more likely than not to 
have been due to problems in care, and evidence of learning and action that is happening 
as a consequence of that information in Quality Accounts from June 2018. 
 
Accountability 
10. Mortality governance should be a key priority for Trust boards. Executives and non-
executive directors should have the capability and capacity to understand the issues 
affecting mortality in their Trust and provide necessary challenge. 
 
11. This National Guidance on Learning from Deaths should be read alongside the Serious 
Incident Framework. Trust boards are accountable for ensuring compliance with both these 
frameworks. They should work towards achieving the highest standards in mortality 
governance.  However, different organisations will have different starting points in relation to 
this agenda and it will take time for all Trusts to meet such standards. Over time this guidance 
is likely to be updated to include wider providers of NHS care and whole healthcare systems. 
 
Responding to Deaths 
12. Each Trust should have a policy in place that sets out how it responds to the deaths of 
patients who die under its management and care. The standards expected of Trusts are 
set out at Annex C.   
 
13. Boards should take a systematic approach to the issue of potentially avoidable mortality and 
have robust mortality governance processes. This will allow them to identify any areas of 
                                                             
4  https://www.gov.uk/government/speeches/cqc-review-of-deaths-of-nhs-patients] 

 

failure of clinical care and ensure the delivery of safe care. This should include a mortality 
surveillance group with multi-disciplinary and multi-professional membership, regular mortality 
reporting to the Board at the public section of the meeting with data suitably anonymised, and 
outputs of the mortality governance process including investigations of deaths being 
communicated to frontline clinical staff.  
 
Death Certification, Case Record Review and Investigation 
14. There are three levels of scrutiny that a provider can apply to the care provided to 
someone who dies; (i) death certification; (ii) case record review; and (iii) investigation. 
They do not need to be initiated sequentially and an investigation may be initiated at any 
point, whether or not a case record review has been undertaken (though a case record 
review will inform the information gathering phase of an investigation together with 
interviews, observations and evidence from other sources). For example, the apparent 
suicide of an in-patient would lead to a Serious Incident investigation being immediately 
instigated in advance of death certification or any case record review. The three 
processes are summarised below: 
 
(i)  Death Certification: In the existing system of death certification in England, deaths 
by natural causes are certified by the attending doctor.  Doctors are encouraged to report 
any death to the coroner that they cannot readily certify as being due to natural causes. 
Reforms to death certification, when implemented in England (and Wales), will result in 
all deaths being either scrutinised by a Medical Examiner or investigated by the Coroner 
in prescribed circumstances. Additionally, Medical examiners will be mandated to give 
bereaved relatives a chance to express any concerns and to refer to the coroner any 
deaths appearing to involve serious lapses in clinical governance or patient safety. 
 
(ii)  Case Record Review: Some deaths should be subject to further review by the 
provider, looking at the care provided to the deceased as recorded in their case records 
in order to identify any learning.  At a minimum, providers should require reviews of: 
 
i. 
all deaths where bereaved families and carers, or staff, have raised a significant 
concern about the quality of care provision
ii. 
all in-patient, out-patient and community patient deaths of those with learning 
disabilities (the LeDeR review process outlined at Annex D should be adopted in 
those regions where the programme is available otherwise Structured Judgement 
Review or another robust and evidence-based methodology should be used) and 

 

with severe mental illness;  
iii.  all deaths in a service specialty, particular diagnosis or treatment group where 
an ‘alarm’ has been raised with the provider through whatever means (for example 
via a Summary Hospital-level Mortality Indicator or other elevated mortality alert, 
concerns raised by audit work, concerns raised by the CQC or another regulator); 
iv.  all deaths in areas where people are not expected to die, for example in relevant 
elective procedures; 
v. 
deaths where learning will inform the provider’s existing or planned 
improvement work, for example if work is planned on improving sepsis care, 
relevant deaths should be reviewed, as determined by the provider. To maximise 
learning, such deaths could be reviewed thematically; 
vi.  a further sample of other deaths that do not fit the identified categories so that 
providers can take an overview of where learning and improvement is needed most 
overall. This does not have to be a random sample, and could use practical sampling 
strategies such as taking a selection of deaths from each weekday. 
 
The above minimum requirements are additional to existing requirements for providers 
to undertake specific routes of reporting, review or investigations for specific groups of 
patient deaths, such as deaths of patients detained under the Mental Health Act 1983 
(Annex E).  
 
Providers should review a case record review following any linked inquest and issue of a 
“Regulation 28 Report on Action to Prevent Future Deaths” in order to examine the 
effectiveness of their own review process. 
 
Providers should apply rigorous judgement to the need for deaths to be subject to a 
Serious Incident reporting and investigation. For example, there may be instances where 
deaths clearly meet Serious Incident criteria and should be reported as such (whether or 
not a case record review has already been undertaken). Equally, problems identified in 
case record review may lead to the need for investigation whether this is an investigation 
under the Serious Incident Framework or other framework/procedure (see section iii) 
 
(iii) Investigation: Providers may decide that some deaths warrant an investigation and 
should be guided by the circumstances for investigation in the Serious Incident 
Framework. 
   
10 
 

Some deaths will be investigated by other agents, notably the coroner. Indeed, the 
coroner has a duty to investigate any death where there are grounds to suspect that the 
death may have been avoidable. While care should be taken not to compromise such 
investigations, equally waiting until other investigations are completed may cause 
unacceptable delay. A good working relationship and close communication are needed 
to avoid problems. 
 
Providers should review an investigation they undertake following any linked inquest and 
issue of a “Regulation 28 Report to Prevent Future Deaths” in order to examine the 
effectiveness of their own investigation process. If an inquest identifies problems in 
healthcare, providers may need to undertake additional investigation and improvement 
action, regardless of the coroner’s verdict. 
 
Consistency and Judgement in Case Record Review 
15. All Trusts currently undertake some form of mortality review. However there is considerable 
variation in terms of methodology, scope, data capture and analysis, and contribution to 
learning and improvement. To generate learning for improvement in healthcare, clinicians 
and staff should engage in robust processes of retrospective case record review to help 
identify if a death was more likely than not to have been contributed to by problems of care.    
 
16. The Structured Judgement Review (SJR) case note methodology is an approach being 
rolled out by the Royal College of Physicians. Other methodologies exist and Trusts may 
already be using them. Trusts need to be assured that the methodology they are using is 
robust and evidence-based, that it will generate the information they are now being 
required to publish and that their staff are trained and given sufficient time and resources to 
undertake case record reviews and act on what they learn. 
 
17. Case record review assessment is finely balanced and subject to significant inter-reviewer 
variation. It does not support comparison between organisations and should not be used 
to make external judgements about the quality of care provided. 
 
18. The judgement of whether a problem may have contributed to a death requires careful 
review of the care that was provided against the care that would have been expected at the 
time of death. Research has shown that when case record review identifies a death that 
may have been caused by problems in care, that death tends to be due to a series of 
problems none of which would be likely to have caused the death in isolation but which in 
11 
 

link to page 8 link to page 12 combination can contribute to the death of a patient56. Some of these elements of care are 
likely to have occurred prior to the admission and providers should support other 
organisations, for example in primary care, to understand and act on areas where care 
could be improved.   
 
19. Trusts should acknowledge and cooperate with separate arrangements for the review 
(and where appropriate investigation) of certain categories of deaths, for example 
suicides, homicides, and child and maternal deaths. 
 
Objectivity in Case Record Review  
20. To ensure objectivity, case record reviews should wherever possible be conducted by 
clinicians other than those directly involved in the care of the deceased. If the specific 
clinical expertise required only resides with those who were involved in the care of the 
deceased, the review process should still involve clinicians who were not involved in order 
to provide peer challenge. Objectivity of reviews should be a component of clinical 
governance processes. Providers may wish to consider if their review processes should 
additionally be the responsibility of a designated non-executive director who could do this 
by chairing the relevant clinical governance committee. 
 
Investigations 
21. This National Guidance on Learning from Deaths and the Serious Incident Framework are 
complementary. This guidance sets out what deaths should be subject to case record 
review (paragraph 14(ii)), which is inevitably a wider definition than deaths that constitute 
Serious Incidents. Equally, when a death meets Serious Incident criteria there is no need 
to delay the onset of investigation until case record review has been undertaken. A review 
of records will inevitably be undertaken as part of an investigation process. However, 
immediate action to secure additional information and evidence to support full 
investigation should not be lost due an inappropriate requirement for all deaths 
(regardless of nature) to first undergo a case record review.  
 
                                                             
5  Hogan et al. Preventable deaths due to problems in care in English acute hospitals: a retrospective 
case record review study. BMJ Qual Saf2012: 21: 737-45. 
6  Hogan et al. Avoidability of hospital deaths and association with hospital-wide mortality ratios: a 
retrospective case record BMJ 2015; 351:h3239. 
12 
 

link to page 12 22. Inquiries by the coroner 7 and investigations by providers are conducted to understand the 
cause of death and contributing factors. However provider investigations are not 
conducted to hold any individual or organisation to account. Other processes exist for that 
purpose including criminal or civil proceedings, disciplinary procedures, employment law 
and systems of service and professional regulation, including the General Medical Council 
and the Care Quality Commission. In circumstances where the actions of other agencies 
are required then those agencies must be appropriately informed and relevant protocols 
must be followed. 
 
Medical Examiners 
23. The introduction of the Medical Examiner role will provide further clarity about which 
deaths should be reviewed. Medical Examiners will be able to refer the death of any 
patient for review by the most appropriate provider organisation(s) and this new 
mechanism should ensure a systematic approach to selecting deaths for review, 
regardless of the setting or type of care provided in the period before a patient’s death. 
NHS  Improvement and the Department of Health are commissioning research to explore 
whether Medical Examiners are best placed to select which deaths need further review 
and ensure they do not inadvertently miss or over-refer certain types of cases. Prior to the 
implementation of the Medical Examiner system, Trusts are advised to allow for any 
doctors undertaking the certification of death to refer cases for case record review to the 
most relevant organisation.  
 
Learning 
24. Providers should have systems for deriving learning from reviews and investigations and 
acting on this learning.  The learning should be shared with other services across the 
wider health economy where they believe this would benefit future patients, including 
independent healthcare services and social care services. Recommendations within any 
“Regulation 28 Report on Action to Prevent Future Deaths” from the coroner should also 
be integral to a provider’s systems to support learning within and across their organisation 
and local system partners. 
 
25. Regardless of whether the care provided to a patient who dies is examined using case 
record review or an investigation, the findings should be part of, and feed into, robust 
clinical governance processes and structures. The findings should be considered alongside 
                                                             
7  Coroner investigations, A short guide (February 2014) is available from:  
https://www.gov.uk/government/publications/guide-to-coroner-services-and-coroner-investigations-a-
short-guide 

13 
 

other information and data including complaints, clinical audit information, mortality data, 
patient safety incident reports and data and outcomes measures etc. to inform the Trust’s 
wider strategic plans and safety priorities. 
 
26. Where case record review identifies a problem in care that meets the definition of a patient 
safety incident (any unintended or unexpected incident which could have or did lead to harm to 
one or more patients receiving NHS care) then this should be reported via local risk 
management systems to the National Reporting and Learning System (NRLS). 
 
27. All patient safety incidents reported as resulting in death or severe harm to a patient are 
clinically reviewed by the National Patient Safety Team at NHS  Improvement to determine if 
there are implications for national learning and if a response is appropriate.  Any deaths that 
are identified via case record review as due to problems in healthcare would meet the criteria 
for NRLS reporting. More information on the national process is available at 
https://improvement.nhs.uk/resources/patient-safety-alerts. All serious incidents that relate to 
patients should be reported to the NRLS for the same reason. 
 
Cross-system Reviews and Investigations  
28. In many circumstances more than one organisation is involved in the care of any patient who 
dies. Guidance in relation to cross-system reviews and investigations is at Annex H. 
 
Roles and Responsibilities of National Bodies and Commissioners 
29. Guidance is provided at Annex I. The lead roles with overall responsibility for the learning from 
deaths programme at each of the relevant national organisation are provided at Annex K. 
 
 
 
 
 
 
 
 
 
 
 
 
14 
 

Chapter 2 - Bereaved Families  and Carers 
Key Principles 
30. Providers should engage meaningfully and compassionately with bereaved families and 
carers in relation to all stages of responding to a death and operate according to the 
following key principles below. 
 
BEREAVED FAMILIES AND CARERS - KEY PRINCIPLES: 
 
•  bereaved families and carers should be treated as equal partners following a 
bereavement;  
•  bereaved families and carers must always receive a clear, honest, 
compassionate and sensitive response in a sympathetic environment;  
•  bereaved families and carers should receive a high standard of bereavement 
care which respects confidentiality, values, culture and beliefs, including being 
offered appropriate support. This includes providing, offering or directing people to 
specialist suicide bereavement support;   
•  bereaved families and carers should be informed of their right to raise concerns 
about the quality of care provided to their loved one;  
•  bereaved families’ and carers’ views should help to inform decisions about 
whether a review or investigation is needed
•  bereaved families and carers should receive timely, responsive contact and 
support in all aspects of an investigation process, with a single point of contact 
and liaison; 
•  bereaved families and carers should be partners in an investigation to the extent, 
and at whichever stages, that they wish to be involved, as they offer a unique and 
equally valid source of information and evidence that can better inform 
investigations; 
•  bereaved families and carers who have experienced the investigation process 
should be supported to work in partnership with Trusts in delivering training for 
staff in supporting family and carer involvement where they want to. 
 
Context 
31. Dealing respectfully, sensitively and compassionately with families and carers of dying or 
deceased patients within the NHS is crucially important. The principles of openness, 
honesty, and transparency as set out in the Duty of Candour should also be applied by 
15 
 

providers in all their dealings with bereaved families and carers. Yet the Care Quality 
Commission’s report Learning, candour and accountability identified that NHS providers are 
continuing to fail too many bereaved families and carers of those who die whilst in their care. 
 
32. When a patient dies under the management and care of a Trust, bereaved families and 
carers should be informed immediately after the death.  People who are bereaved need 
others to recognise and acknowledge their loss. Recognition by professionals, 
appropriately expressed, may be particularly valued. Communication at the time of a 
death, and afterwards, should be clear, sensitive and honest.  Bereaved families and 
carers should be given as much information as possible in line with the Duty of Candour 
for providers. Every effort should be made to hold these discussions in a private, 
sympathetic environment, without interruptions.  Providers should ensure that their staff, 
including family liaison officers where available, have the necessary skills, expertise and 
knowledge to engage with bereaved families and carers. This includes recognising and 
dealing with common issues such as family members feeling guilty about their loss. 
 
33. All too often the terms of the conversation people have with the NHS  about a concern or 
complaint are set by the organisation. Organisations can often be too quick to dismiss or 
explain away concerns, compounding the grief of bereaved families and carers with 
obfuscation and a lack of openness. Paying close attention to what bereaved families and 
carers say can offer an invaluable source of insight to improve clinical practice. Listening 
to them goes hand in hand with the Duty of Candour. In particular, bereaved families and 
carers should be asked if they had concerns about the quality of care received by the 
deceased to inform decisions about the need to undertake a case record review or 
investigation.   
 
34. When reviewing or investigating possible problems with care, involvement of bereaved 
families and carers begins with a genuine apology. Saying sorry is not an admission of 
liability and is the right thing to do. The appropriate staff member should be identified for 
each case, including to explain what went wrong promptly, fully and compassionately. 
This may include clinicians involved in the case but this may not always be appropriate 
and should be considered on a case by case basis. 
 
35. Depending on the nature of the death, it may be necessary for several organisations to 
make contact with those affected. This should be discussed with the bereaved families 
and carers and a co-ordinated approach should be agreed with them and the 
16 
 

organisations involved. If other patients and service users are involved or affected by the 
death they should be offered the appropriate level of support and involvement. 
 
36. The provider should ensure that the deceased person’s General Practitioner is informed 
of the death and provided with details of the death as stated in the medical certificate at 
the same time as the family or carers. The GP should be informed of the outcome of any 
investigation. 
 
Bereavement Support 
37. Bereavement can influence every aspect of well-being.  Providers should offer a 
bereavement service for families and carers of people who die under their management and 
care (including offering or directing people to suicide bereavement support) that offers a 
caring and empathetic service at a time of great distress and sadness. This includes offering 
support, information and guidance. This should include bereavement advisors to help 
families and carers through the practical aspects following the death of a loved one such as: 
 
•  arranging completion of all documentation, including medical certificates; 
•  the collection of personal belongings; 
•  post mortem advice and counselling; 
•  deaths referred to the coroner; 
•  emotional support, including counselling; 
•  collection of the doctor’s Medical Certificate of Cause of Death and information 
about registering a death at the Registrar’s Office; 
•  details of the doctor’s Medical Certificate of Case of Death (this is needed to register 
a death at the Registrar’s Office).   
 
38. The following should also be considered: 
 
•  timely access to an advocate (independent of the Trust) with necessary skills for 
working with bereaved and traumatised individuals;  
•  support with transport, disability, and language needs; 
•  support during and following an investigation. This may include counselling or 
signposting to suitable organisations that can provide bereavement or post-traumatic 
stress counselling, with attention paid to the needs of young family members, especially 
siblings; 
17 
 

•  further meetings with the organisations involved or support in liaising with other 
agencies such as the police. 
 
Review 
39. If the care of a patient who has died is selected for case record review providers should: 
 
•  have formed that decision based on the views of the family and carers. Providers 
should require reviews in cases where family and carers have raised a significant 
concern about the quality of care provision (paragraph 14 (ii)(i)); 
•  communicate to the family and carers the findings of the review if any problems with 
care are identified and any lessons the review has contributed for the future. 
 
Investigations 
40. If a provider feels that an investigation into a death is needed, early contact should have been 
made with bereaved families and carers so that their views helped to inform the decision. 
 
41. Bereaved families and carers will expect to know: what happened; how; to the extent 
possible at the time, why it happened; and what can be done to stop it happening again to 
someone else. If a provider proceeds with an investigation, skilled and trained 
investigators need to be able to explain to bereaved families and carers the purpose of 
the investigation which is to understand what happened. If problems are identified, the 
investigation should be clear why and how these happened so that action can be taken to 
prevent the same mistakes from occurring again. 
 
42. Provided the family or carer is willing to be engaged with regarding the investigation, an 
early meeting should be held to explain the process, how they can be informed of 
progress, what support processes have been put in place and what they can expect from 
the investigation. This should set out realistic timescales and outcomes. There should be 
a named person as a consistent link for the families and carers throughout the 
investigation, for example a family liaison officer. 
 
43. Bereaved families and carers should:  
 
•  be made aware, in person and in writing, as soon as possible of the purpose, 
rationale and process of the investigation to be held;  
18 
 

link to page 13 •  be asked for their preferences as to how and when they contribute to the process of 
the investigation and be kept fully and regularly informed, in a way that they have 
agreed, of the process of the investigation; 
•  have the opportunity to express any further concerns and questions and be offered a 
response where possible, with information about when further responses will be provided; 
•  have a single point of contact to provide timely updates, including any delays, the 
findings of the investigation and factual interim findings. This may disclose 
confidential personal information for which consent has been obtained, or where 
patient confidentiality is overridden in the public interest. This should be considered 
by the organisation’s Caldicott Guardian and confirmed by legal advice in relation to 
each case;  
•  have an opportunity to be involved in setting any terms of reference for the investigation 
which describe what will  be included in the process and be given expectations about the 
timescales for the investigation including the likely completion date;  
•  be provided with any terms of reference to ensure their questions can be reflected 
and be given a clear explanation if they feel this is not the case;  
•  have an opportunity to respond on the findings and recommendations outlined in any 
final report; and, 
•  be informed not only of the outcome of the investigation but what processes have 
changed and what other lessons the investigation has contributed for the future. 
 
Guidance 
44. NHS  England will develop guidance for bereaved families and carers, identifying good 
practice for local services on the information that families say they would find helpful. It 
will cover what families can expect by way  of local support in relation to investigations and 
what to expect when services have identified the death as complex or needing 
an independent investigation so potentially involving longer timeframes and multiple 
agency involvement. 
 
45. Public Health England has published guidance which provides advice to local authorities 
and the NHS  on developing and providing suicide bereavement support .  
 
 
 
                                                             

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/590838/support_after_
a_suicide.pdf 

19 
 

 
 
 
 
 
 
Annexes 
 
 
 
 
 
 
 
 
 
20 
 

Annex A - Board Leadership 
 
BOARD LEADERSHIP  - KEY POINTS 
 
The board should ensure that their organisation: 
•  has an existing board-level leader acting as patient safety director to take 
responsibility for the learning from deaths agenda and an existing non-executive 
director to take oversight of progress; 
•  pays particular attention to the care of patients with a learning disability or mental 
health needs;  
•  has a systematic approach to identifying those deaths requiring review and 
selecting other patients whose care they will review;  
•  adopts a robust and effective methodology for case record reviews of all selected 
deaths (including engagement with the LeDeR programme) to identify any concerns or 
lapses in care likely to have contributed to, or caused,  a death and possible areas for 
improvement, with the outcome documented;  
•  ensures case record reviews and investigations are carried out to a high quality
acknowledging the primary role of  system factors within or beyond the organisation 
rather than individual errors in the problems that generally occur;  
•  ensures that mortality reporting in relation to deaths, reviews, investigations and 
learning is regularly provided to the board in order that the executives remain 
aware and non-executives can provide appropriate challenge. The reporting should be 
discussed at the public section of the board level with data suitably anonymised; 
•  ensures that learning from reviews and investigations is acted on to sustainably 
change clinical and organisational practice and improve care, and reported in annual 
Quality Accounts
•  shares relevant learning across the organisation and with other services where the 
insight gained could be useful;  
•  ensures sufficient numbers of nominated staff have appropriate skills through 
specialist training and protected time as part of their contracted hours to review and 
investigate deaths; 
•  offers timely, compassionate and meaningful engagement with bereaved 
families and carers in relation to all stages of responding to a death; 
•  acknowledges that an independent investigation (commissioned and delivered 
entirely separately from the organisation(s) involved in caring for the patient) may in 
21 
 

some circumstances be warranted, for example, in cases where it will  be difficult for an 
organisation to conduct an objective investigation due to its size or the capacity and 
capability of the individuals involved; and, 
•  works with commissioners to review and improve their respective local 
approaches following the death of people receiving care from their services. 
Commissioners should use information from providers from across all deaths, including 
serious incidents, mortality reviews and other monitoring, to inform their commissioning 
of services. This should include looking at approaches by providers to involving 
bereaved families and carers and using information from the actions identified following 
reviews and investigations to inform quality improvement and contracts etc. 
 
 
 
 
 
 
 
 
 
 
 
 
22 
 

Annex B - Non-Executive Directors   
Context 
1.  The board of directors of an NHS Trust or Foundation Trust is collectively responsible for 
ensuring the quality and safety of healthcare services delivered by the Trust, and in the 
case of a Foundation Trust taking into consideration the views of the board of governors.  
 
2.  Boards must ensure robust systems are in place for recognising, reporting, reviewing or 
investigating deaths and learning from avoidable deaths that are contributed to by lapses 
in care. Providers should ensure such activities are adequately resourced. 
Commissioners are accountable for quality assuring the robustness of providers’ 
systems so that providers develop and implement effective actions to reduce the risk of 
avoidable deaths, including improvements when problems in the delivery of care within 
and between providers are identified.   
 
3.  All Trust directors, executive and non-executive, have a responsibility to constructively 
challenge the decisions of the board and help develop proposals on strategy. Non-
executive directors, in particular, have a duty to ensure that such challenge is made.  
They play a crucial role in bringing an independent perspective to the boardroom and 
should scrutinise the performance of the provider’s management in meeting agreed goals 
and objectives and monitor the reporting of performance.  Non-executive directors should 
satisfy themselves as to the integrity of financial, clinical and other information, and that 
clinical quality controls and systems of risk management, for example, are robust and 
defensible.  
 
Learning from Deaths 
4.  Executive and non-executive directors have a key role in ensuring their provider is learning 
from problems in healthcare identified through reviewing or investigating deaths by ensuring 
that: 
 
•  the processes their organisation have in place are robust, focus on learning and can 
withstand external scrutiny, by providing challenge and support; 
•  quality improvement becomes and remains the purpose of the exercise, by 
championing and supporting learning, leading to meaningful and effective actions 
that improve patient safety and experience, and supporting cultural change; and 
23 
 

•  the information the provider publishes is a fair and accurate reflection of its 
achievements and challenges.    
 
5.  From April 2017, providers will start to collect and publish new data to monitor trends in 
deaths. Alongside this, they will need to establish an ongoing learning process. Board 
oversight of this process is as important as board oversight of the data itself. As a critical 
friend, non-executive directors should hold their organisation to account for its approach 
and attitude to patient safety and experience, and learning from all deaths, particularly 
those assessed as having been avoidable.  The roles and responsibilities of non-
executive directors include:  
 
i.  Understand the process: ensure the processes in place are robust and can 
withstand external scrutiny, by providing challenge and support. For example: 
•  be curious about the accuracy of data and understand how it is generated; who is 
generating it, how are they doing this, is the approach consistent across the 
Trust, are they sufficiently senior/experienced/trained? 
•  seek similar data and trend information from peer providers, to help challenge 
potential for improvements in your own organisation’s processes, but understand 
limitations of any direct comparisons;   
•  ensure timely reviews/investigations (what is the interval between death and 
review or investigation?), calibre of reviewer/investigator and quality of the review 
or investigation; 
•  is the Care Record Review process objective, conducted by clinicians not directly 
involved in the care of the deceased?  
•  how was the case-record review selection done? For example, does selection 
reflect the evidence base which suggests older patients who die or those where 
death may be expected are no less likely to have experienced problems in 
healthcare that are associated with potentially preventable death?  Does it ensure 
all vulnerable patient groups (not just those with learning disabilities or mental 
health needs) are not disadvantaged? 
•  are deaths of people with learning disabilities reviewed according to the LeDeR 
methodology?   
•  for coordination of responses to reviews/investigations through the provider’s 
clinical governance processes, who is responsible for preparing the report, do 
problems in care identified as being likely to have contributed to a death feed into 
the organisation’s Serious Incident processes? 
24 
 

ii. 
Champion and support learning and quality improvement such as: 
•  ensuring the organisation has a long-term vision and strategy for learning and 
improvement and is actively working towards this; 
•  understanding the learning being generated, including from where deaths may be 
expected but the quality of care could have been better; 
•  understanding how the learning from things going wrong is translated into 
sustainable effective action that measurably reduces the risks to patients - 
ensuring that learning and improvements are reported to the board and relevant 
providers; 
•  supporting any changes in clinical practice that are needed to improve care 
resulting from this learning; 
•  ensuring families and carers are involved reviews and investigations, and that 
nominated staff have adequate training and protected time to undertake these 
processes; 
•  paying attention to the provision of best practice and how the learning from this 
can be more broadly implemented. 
 
iii.  Assure published information; ensure that information published is a fair and 
accurate reflection of the provider’s achievements and challenges, such as: 
•  ensuring that information presented in board papers is fit for publication i.e. it is 
meaningful, accurate, timely, proportionate and supports improvement; 
•  checking that relevant team are working towards a timely quarterly publication, in 
line with the Quality Accounts regulations and guidance; 
•  checking that arrangements are in place to invite, gather and act on stakeholder 
feedback on a quarter by quarter basis; 
•  ensuring the organisation can demonstrate to stakeholders that “this is what we 
said we would do, and this is what we did” (learning and action), and explain the 
impact of the quality improvement actions.     
 
 
 
 
25 
 

Annex C - Responding to Deaths 
Trusts should have a policy in place that sets out how they respond to the deaths of patients 
who die under their management and care.  
 
POLICY FOR RESPONDING  TO DEATHS  - KEY POINTS 
 
The policy should include how providers: 
•  determine which patients are considered to be under their care and included 
for case record review if they die (it should also state which patients are 
specifically excluded);   
•  report the death within the organisation and to other organisations who may 
have an interest (including the deceased person’s GP), including how they 
determine which other organisations should be informed;  
•  respond to the death of an individual with a learning disability (Annex D) or 
mental health needs (Annex E), an infant or child death (Annex F) and a stillbirth 
or maternal death (Annex G) and the provider’s processes to support such deaths; 
•  review the care provided to patients who they do not consider to have been 
under their care at the time of death but where another organisation suggests 
that the Trust should review the care provided to the patient in the past
•  review the care provided to patients whose death may have been expected, for 
example those receiving end of life care; 
•  record the outcome of their decision whether or not to review or investigate the 
death, which should have been informed by the views of bereaved families and 
carers;   
•  engage meaningfully and compassionately with bereaved families and carers - 
this should include informing the family/carers if the provider intends to review or 
investigate the care provided to the patient. In the case of an investigation, this 
should include details of how families/carers will be involved to the extent that they 
wish to be involved. Initial contact with families/carers are often managed by the 
clinicians responsible for the care of the patient. Given that providers must offer 
families/carers the opportunity to express concerns about the care given to patients 
who have died, then the involvement of clinicians who cared for the patient may be 
considered a barrier to raising concerns. Providers should therefore offer other routes 
for doing this;   
•  offer guidance, where appropriate, on obtaining legal advice for families, 
26 
 

carers or staff. This should include clear expectations that the reasons, purpose and 
involvement of any lawyers by providers will be communicated clearly from the 
outset, preferably by the clinical team, so families and carers understand the reasons 
and are also offered an opportunity to have their own advocates. 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
27 
 

link to page 19 link to page 28 link to page 28 Annex D - Learning Disabilities 
Context 
1.  Since the 1990s, there have been a number of reports and case studies which have 
consistently highlighted, that in England, people with learning disabilities die younger than 
people without learning disabilities.  The Confidential Inquiry of 2010-2013 into premature 
deaths of people with learning disabilities (CIPOLD) reported that for every one person in 
the general population who died from a cause of death amenable to good quality care, 
three people with learning disabilities would do so 9. Overall, people with learning 
disabilities currently have a life expectancy at least 15 to 20 years shorter than other 
people10.  
 
2.  A concerning finding from CIPOLD was that assumptions were sometimes made that the 
death of a person with learning disabilities was ‘expected’ or even inevitable, because that 
person had learning disabilities. As with the CQC report of 2016 11, CIPOLD also identified 
deaths that should have been, but were not, reported to mandatory review processes, 
including safeguarding reviews and to the coroner. 
 
3.  The lives of people with learning disabilities often involve a complex array of service 
provision with multiple care and support staff. If we are to improve service provision for 
people with learning disabilities and their families, and reduce premature deaths, we need 
to look wider than NHS-related circumstances leading to a person’s death, in order to 
identify the wider range of potentially avoidable contributory factors to their death. A 
cross-sector approach to reviewing deaths of people with learning disabilities is 
imperative; one that includes families, primary and secondary healthcare, and social and 
third sector care providers. Such a balanced approach across acute and other settings is 
needed from the outset of a review process, in order to accurately determine if there are 
any concerns about the death, or to identify examples of best practice that could lead to 
service improvement. 
 
                                                             
9  Heslop P, Blair P, Fleming P, Hoghton M, Marriott A, Needleman D, Russ L. (2013)  Confidential 
Inquiry into premature deaths of people with learning disabilities. Bristol: University of Bristol. 
10  Glover G,et al, 2017. Williams R. Heslop P, Oyinlola J, Grey J. (2016) Mortality in people with 
intellectual disabilities in England. Journal of Intellectual Disabilities Research, 61, 1, 62-74; Health 
and Care of People with Learning Disabilities, 2014-15
, NHS Digital, 9 December 2016.  
11  Learning, candour and accountability: A review of the way NHS Trusts review and investigate the 
deaths of patients in England
, Care Quality Commission December 2016. 
28 
 

link to page 28 link to page 29 4.  There is unequivocal evidence that demands additional scrutiny be placed on the deaths 
of people with learning disabilities across all settings. This work has already been started 
by the Learning Disabilities Mortality Review (LeDeR) programme, commissioned by 
Healthcare Quality Improvement Partnership (HQUIP) for NHS  England.  Once fully rolled 
out, the programme will receive notification of all deaths of people with learning 
disabilities, and support local areas to conduct standardised, independent reviews 
following the deaths of people with learning disabilities aged 4 to 74 years of age.  These 
will  be conducted by trained reviewers.    
 
5.  The purpose of the local reviews of death is to identify any potentially avoidable factors 
that may have contributed to the person’s death and to develop plans of action that 
individually or in combination, will guide necessary changes in health and social care 
services in order to reduce premature deaths of people with learning disabilities. 
 
Scope 
6.  A conceptual definition of learning disabilities is used in the Learning Disabilities White 
Paper ‘Valuing People’12 (2001). 
 
7.  At present, NHS England is working with  NHS  Digital to explore the options and potential 
of ‘flagging’ the records of people with learning disabilities on the NHS Spine 13. Over time, 
this could provide an access point for identifying that a person who has died had learning 
disabilities. 
 
8.  The LeDeR programme currently supports local reviews of deaths of people with learning 
disabilities aged 4 years and over. The lower age limit is set at 4 years of age because 
before that age, it can be difficult to be sure that a child has learning disabilities as defined 
above.  
 
Operationalising Mortality Reviews of People with Learning Disabilities 
9.  The LeDeR programme has an established and well-tested methodology for reviewing the 
deaths of people with learning disabilities.  
 
 
                                                             
12  Valuing People: A New Strategy for Learning Disability for the 21st Century, Department of Health, 
2001. LeDeR briefing paper. 
13  Spine supports the IT infrastructure  for health and social care in England, joining together 
over 23,000 healthcare IT systems in 20,500 organisations. 
29 
 

link to page 29 Current process 
Summary of 
Collation and 
Allocation 
Full 
Notification 
Initial 
multiagency 
recommendations 
reporting  of 
of death 
to case 
and actions 
recommend-
reviewer 
review 
review if 
reported to key 
ations and 
indicated 
agencies 
actions 
 
 
10. All deaths of people with learning disabilities are notified to the programme. Those 
meeting the inclusion criteria for mortality review receive an initial review of their death by 
an independent, trained reviewer.  
 
11. The standardised review process involves discussing the circumstances leading up to the 
person’s death with someone who knew them well  (including family members wherever 
possible), and scrutinising at least one set of relevant case notes. Taking a cross-agency 
approach, the reviewer develops a pen portrait of the individual and a comprehensive 
timeline of the circumstances leading to their death, identifies any best practice or 
potential areas of concern, and makes a decision, in conjunction with others if necessary, 
about whether a multi-agency review is indicated. 
 
12. A full multi-agency review is required if the criteria for the current themed priority review 
are met (death of a person from a Black and Minority Ethnic background or aged 18-24), 
or where an assessment of the care received by the person indicates deficiencies in one 
or more significant areas. A full multi-agency review is recommended if there have been 
any concerns raised about the death, if any ‘red flag alerts’14 have been identified in the 
initial review, or if the reviewer thinks that a full multi-agency review would be appropriate. 
The purpose of the multi-agency review is to gain further learning which will contribute to 
improving practice and service provision for people with learning disabilities, so the review 
process concludes with an agreed action plan and recommendations that are fed back to 
the regional governance structures for the programme. 
                                                             
14  ‘Red flag’ alerts are those identified in the initial review that may suggest potential problems with 
the provision of care e.g. no evidence that an assessment of mental capacity has been considered 
when this would have been appropriate; delays in the person’s care or treatment that adversely 
affected their health.  
30 
 

link to page 30 13. The LeDeR programme currently operates independently of, but communicates and 
cooperates with, other review and investigatory processes. This enables an integrated 
approach to initial reviews of deaths of people with learning disabilities to be taken 
whenever possible, so as to avoid unnecessary duplication but ensure that the specific 
focus of the different review or investigation processes is maintained. 
 
14. Alignment of LeDeR with SJR for example will  enable a balanced approach to be taken to 
reviewing deaths of people with learning disabilities that draws on contributions from 
across acute and other settings. Deaths of people with learning disabilities that occur in 
hospital settings should be subject to the LeDeR review process in order that insights 
from families, primary and secondary healthcare, and social and third sector care 
providers are all included in the mortality review. 
 
15. The LeDeR programme provide annual reports on its findings, collating learning and 
recommendations at the regional and national level on how best to take forward the 
learnings across the NHS. 
 
16. Because of the different methodology adopted by the LeDeR programme, it would not be 
appropriate to use the same definition of ‘avoidable death’ as used by the SJR, nor to 
compare rates of avoidable deaths across and between the two review processes. The 
LeDeR programme will continue to use the Child Death Review Process terminology of 
‘potentially avoidable contributory causes of death’ and the Office for National Statistics 
definition of avoidable deaths using ICD-10 coding of the underlying cause of death 15
 
Integration of the LeDeR Process into National Level Mortality Review Structures 
17. When a death of a person with learning disabilities occurs, mandatory review processes 
need to take precedence, working with the LeDeR programme reviewers to ensure that a 
coordinated approach is taken to the review of the death in order to minimise duplication 
and bring in the learning disabilities expertise of the LeDeR reviewers, whilst recognising 
that some investigatory processes will be more focused than that of LeDeR which is 
cross-agency in nature and may require the provision of additional information. 
 
                                                             
15  Office for National Statistics (2016) Revised Definition of Avoidable Mortality and New Definition for 
Children and Young People. 
https://www.ons.gov.uk/aboutus/whatwedo/statistics/consultationsandsurveys/allconsultationsandsurv
eys/reviewofavoidablemortalitydefinition
 
 
31 
 

18. Learning and recommendations from LeDeR reviews will identify opportunities for 
improvement at the local, regional and national level. Governance structures that can 
support the cross-agency implementation of recommendations from mortality reviews are 
required at all levels, but in particular for the reviews of deaths of people with learning 
disabilities. Such structures exist in the form of regional steering groups for the LeDeR 
programme, and these are usually best placed within the safeguarding framework. Not all 
deaths of people with learning disabilities are safeguarding issues; however the existing 
multi-agency framework and statutory responsibility mean that this is a natural ‘home’ for 
governance of mortality reviews. 
 
Guidance for Providers 
19. Key points to note are: 
•  All deaths of people with learning disabilities aged four years and older are subject to 
review using LeDeR methodology; 
•  The LeDeR programme is currently being rolled out across England. Full coverage is 
anticipated in all Regions by the end of 2017. If there is a death of a person with 
learning disabilities in an acute setting in an area that is not yet covered by the 
LeDeR programme, Trusts are recommended to use the SJR process or a 
methodology of equivalent quality that meets the requirements for the data that must 
be collected as an interim measure; 
•  If a Trust wishes to complete its own internal mortality review, it is recommended that 
it uses the LeDeR initial review process and documentation available at: 
http://www.bristol.ac.uk/media-
library/sites/sps/leder/Initial%20Review%20Template%20version%201.2.pdf The 
provider can then submit that as an attachment to the LeDeR notification web-based 
platform once their internal review is completed; 
•  Once the LeDeR review has been completed, a copy will be sent to the relevant 
governance body at the Trust where the death occurred; 
•  Trusts are encouraged to identify appropriate personnel to undertake LeDeR training 
and review processes. Reviewers would be expected to conduct reviews 
independent of the Trust in which they work.  
 
 
 
 
 
32 
 

link to page 31 link to page 33 Annex E - Mental Health 
1.  Physical and mental health are closely linked.  People with severe and prolonged mental 
illness are at risk of dying on average 15 to 20 years earlier than other people16. In 
addition, people with long term physical illnesses suffer more complications if they also 
develop mental health problems. 
 
2.  Reporting and reviewing of any death of a patient with mental health problems should 
consider these factors i.e. premature death of those with a mental disorder and the 
increased risk of complications for those with physical and mental health difficulties. 
 
Inpatients detained under Mental Health Act 
3.  Regulations17 require mental health providers to ensure that any death of a patient 
detained under the Mental Health Act (1983) is reported to the Care Quality Commission 
without delay.  In 2015, the Care Quality Commission reported concern that providers 
were failing to make this notification in 45% of cases. The Commission has since updated 
its notifications protocols to ensure that providers ensure they report in a timely way. 
 
4.  Under the Coroners and Justice Act 2009, coroners must conduct an inquest into a death 
that has taken place in state detention, and this includes deaths of people subject to the 
Mental Health Act. Providers are also required to ensure that there is an appropriate 
investigation into the death of a patient in state detention under the Mental Health Act 
(1983). 
 
5.  In circumstances where there is reason to believe the death may have been due, or in 
part due to, to problems in care - including suspected self-inflicted death - then the death 
must be reported to the provider’s commissioner(s) as a serious incident and investigated 
appropriately. Consideration should also be given to commissioning an independent 
investigation as detailed in the Serious Incident Framework
 
People with Mental Health Disorders in Prisons 
6.  Evidence shows that there is a high incidence of mental health problems in prisons: 72% 
of adult male and 71% of female prisoners may have 2 or more mental disorders (e.g. 
                                                             
16  The Five Year Forward View For Mental Health (NHS England, 2016) is available at: 
https://www.england.nhs.uk/wp-content/.../Mental-Health-Taskforce-FYFV-final.pdf 
17  Regulation 17, Care Quality Commission (Registration) Regulations 2009 
33 
 

link to page 33 link to page 34 personality disorder, psychosis, anxiety and depression, substance misuse); 20% have 4 
or more mental disorders. 
 
7.  There have been large increases in the number of natural and non-natural deaths in 
prisons over the most recent five-year reporting period. The increase in recent years in 
non-natural deaths in prisons are due to a number of factors. Prisons contain a high 
proportion of vulnerable individuals, many of whom have experienced negative life events 
that increase the likelihood of suicide or self-harm. Issues that increase risk include 
drug/alcohol abuse, family background, social disadvantage or isolation, previous sexual 
or physical abuse, and mental health problems. The increase in part reflects an ageing 
prison population. Prisons are also very challenging environments particularly so for those 
prisoners who have a learning disability. Average estimates of prevalence of learning 
disabilities amongst adult offenders in the UK is thought to be between 2-10%. This figure 
is much higher for children who offend 18. Prisoners with learning disabilities are also more 
likely than other prisoners to suffer mental ill health. As such, the mental wellbeing of 
prisoners with learning disabilities should be a key consideration for healthcare staff of 
NHS providers along with all other prison staff.   
 
8.  The Serious Incident Framework states that in prison and police custody, any death will 
be referred (by the relevant organisation) to the Prison and Probation Ombudsman (PPO) 
or the Independent Police Complaints Commission (IPCC) who are responsible for 
carrying out the relevant investigations. Healthcare providers must fully support these 
investigations where required to do so. The PPO has clear expectations in relation to 
health involvement in PPO investigations into death in custody. Guidance published by 
the PPO19 must be followed by those involved in the delivery and commissioning of NHS 
funded care within settings covered by the PPO.  
 
 
 

                                                             
18  Equal Access Equal Care, Guidance for Prison Healthcare Staff treating Patients with Learning 
Disabilities (2015) available at https://www.england.nhs.uk/.../equal-access-equal-care-guidance-
patients-ld.pdf 
19  Guidance is available online: http://www.ppo.gov.uk/updated-guidance-for-clinical-reviews/  
34 
 

Annex F - Children and Young People 
Infant and Child Mortality 
1.  Over the last 20 years, the UK has gone from having one of the lowest mortality rates for 
0 to 14 year olds in Europe to one of the highest1. In 2014, 4, 419 children and young 
people aged 0 to 18 years old died in England and Wales. 24% of deaths in children and 
young people are thought to be preventable2.  In the year ending March 2016, 68% of all 
deaths occurred in hospital, 22% in the home, 4% in a public place, and 4% in a hospice. 
In the year ending March 2016, 32% of all deaths occurred following a perinatal or 
neonatal event, 26% in children with chromosomal, genetic and congenital anomalies, 
8% in children with ‘sudden unexpected and unexplained’ death, 7% in children with 
malignancy, 6% in children with acute medical or surgical illnesses, 6% in children with 
infection, 5% in children suffering trauma, 3% in young people taking their life, and 2% 
following deliberately inflicted injury, abuse or neglect2. 
 
2.  In child mortality review, professionals have moved away from defining ‘avoidability’ to 
instead using the language of ‘a preventable death’ where the latter is defined as a death 
in which ‘modifiable factors may have contributed to the death and which, by means of 
nationally or locally achievable interventions, could be modified to reduce the risk of 
future child deaths’3. In the year ending March 2016, 54% of deaths in hospital and 31% 
of death in the home were identified as having modifiable factors. Most modifiable factors 
are found in children dying from perinatal/neonatal events, followed by trauma, followed 
by those with chromosomal, genetic and congenital anomalies2.. 
 
National Data on Causes of Death and International Comparisons4 
3.  The UK ranks 15 out of 19 Western European countries on infant (under one year of 
age) mortality and has one of the highest rates for children and young people in Western 
Europe5. There is a strong association between deprivation and mortality; for example 
infant mortality is more than twice as high in the lowest compared with the highest socio-
economic groups6. 
 
Infants (under 1 year) 
4.  Around 60% of deaths during childhood occur in infancy. Infant mortality can be split into 
neonatal mortality (deaths 0–27 days) and post-neonatal mortality (28–365 days). Births 
without signs of life (stillbirths if after 24 weeks of pregnancy) do not contribute to infant 
mortality but are also an important indicator of maternal and child health. The Infant 
35 
 

Mortality Rate (IMR) is an indicator of both population health and the quality of 
healthcare service. It is also a key international indicator in the United Nation's 
Sustainable Development Goals and in UNICEF  international comparisons. 
 
5.  Neonatal mortality accounts for between 70% and 80% of infant deaths. The great 
majority of neonatal deaths are due to perinatal causes, particularly preterm birth, and 
are strongly related to maternal health, as well as congenital malformations. The 
remainder of infant deaths are post-neonatal and are due to a broad range of causes 
including sudden infant death syndrome (SIDS). Stillbirths (defined in the UK as a baby 
born without signs of life after 24 completed weeks of pregnancy) account for half of all 
deaths during the perinatal period. In 2014, the IMR across the UK was 3.9 deaths per 
1,000 live births. Although there has been an overall decline in the IMR across the UK 
over the past 45 years, in recent years the reduction in infant mortality in the UK has not 
equalled the gains observed in comparable countries. An international study of mortality 
in the UK compared with similar wealthy countries in Europe and elsewhere showed the 
UK  to have IMR  in 1970 similar to the average of the group, but that the UK had become 
among the worst performing 10% by 20087. 
 
6.  Social inequalities play a role in almost all the leading causes of infant death. The 
mechanisms underlying this social gradient are related to increased risk of preterm 
delivery in more deprived groups, as well as to maternal health during pregnancy (for 
example, smoking, poor nutrition, substance abuse) and uptake of recommended 
practices such as breastfeeding and safe infant sleeping positions8. Maternal age is also 
associated with infant mortality6. Many of the causes of infant mortality are preventable 
and necessitate actions at both a population and individual level9: 
 
•  maximising  the health and wellbeing of women before conception and during 
pregnancy (smoking cessation programmes, promotion of breastfeeding and 
promoting healthy weight in women of childbearing age) 
•  protecting and supporting health promotion and early intervention services (universal 
midwifery and health visiting services for new mothers)  
•  promoting evidence-based research into maternal and infant health, and translating 
findings into improved practice, standards of care, and ultimately policy 
•  identifying best practice and reducing variations in outcomes across health care 
services 
 
 
36 
 

Children (1-9 years) 
7.  The main factors that contribute to death during childhood are different to those that 
contribute to death during infancy or adolescence. The common causes of death 
amongst 1 to 9 year-olds are cancer, injuries and poisonings, congenital conditions and 
neurological and developmental disorders. Injuries and poisonings from external causes 
are the leading cause of death in boys aged one to four years, whilst cancer is the 
leading cause of death in girls of the same age5. For both girls and boys five to nine 
years of age, cancer is the leading cause of death. Very early life also still has an impact 
on mortality in later childhood; children who were born preterm remain more likely to die 
before age 10 years compared to children born at term.  
 
8.  In the period 2012-2014, the mortality rate in children aged 1-9 years in the U.K. was 
12.1 per 100,000 population.  Although the mortality rate has declined across the UK 
since the 1970s, the UK's recent progress has been significantly lower than in other 
wealthy European countries, and concerningly the incidence of death due to diseases 
such as asthma and diabetes is higher than equivalent high-income countries. The scale 
of difference between the UK child mortality rate and the average suggests there are 
around 130 excess deaths of 1- to 9-year-olds each year in the UK10. 
 
9.  Many childhood deaths are preventable. As with infants there is a strong association 
between deprivation, social inequality, and mortality.  Causes amenable to interventions 
include environmental and social factors as well as health service factors and key 
actions include the following9: 
 
•  creating safe environments, including access to information and safety equipment 
schemes to promote safety in the home; 
•  reduce road speed limits in built-up areas to 20mph;  
•  ensuring that clinical teams looking after children with long-term conditions such as 
asthma, epilepsy and diabetes deliver care to the highest standards, incorporating 
good communication, open access for patients and families, use of established tools 
such as the epilepsy passport and asthma plan, adherence to the components 
prevalent in the best practice tariff for diabetes, and address early the optimal 
conditions for safe transition to adult services. Implicit in this is teaching self-
management and ownership of the condition; 
•  increasing the provision of high-quality end-of-life care and access to appropriate 
palliative care; 
37 
 

•  delivering integrated health systems across primary and secondary care; whilst 
providing the optimal configuration of specialist services for children with complex 
conditions needing tertiary care, such as cardiac, renal conditions and children's 
cancer. 
 
Young People (10-19 years) 
10. After the first year of life, adolescence is the life stage when children are most likely to 
die. The factors leading to death in adolescence are different to those in earlier 
childhood, and differ between males and females. The most common causes of death in 
this age group are injuries, violence and suicide, followed by cancer, substance misuse 
disorders and nervous system and developmental disorders.  
 
11. Although the mortality rate in young people has decreased across the UK since the 
1970s, progress recently has been slower than that seen in other wealthy countries10. 
The UK's 'average' adolescent overall mortality today is a mixed picture. Whilst our injury 
mortality rate is amongst the lowest, we have a higher rate of deaths due to ‘non 
communicable diseases’ such as asthma than other equivalent wealthy countries. Social 
inequalities are important since injury and illness are associated with poor environmental 
conditions and hazards such as smoking, alcohol, and drug use8. 
 
12. Many deaths are preventable and key actions include9: 
 
•  reducing deaths from traffic injuries through the introduction of graduated licensing 
schemes;  
•  improving adolescent mental health services; 
•  improving services for children with long term conditions, and especially those 
transitioning to adult care; 
•  increasing the involvement of young people and their families with rare and common 
long-term conditions in developing guidelines, measuring outcomes, service design 
and research trials. 
 
13. Underpinning all efforts to reduce child mortality in England lies an urgent need to collect 
high-quality data to better understand the reasons why children die, to allow accurate 
international comparisons, and to inform health policy. This requires a national system 
for the analysis of child mortality data, as well as improved child death review processes. 
 
 
38 
 

Historical Background to the Process of Child Mortality Review 
14. Since 1st April 2008, Local Safeguarding Children’s Boards in England have had a 
statutory responsibility for Child Death Review (CDR) processes. The relevant legislation 
underpinning such responsibility is enshrined in the Children’s Act 2004 and applies to al  
children under 18 years of age. The processes to be followed when a child dies are 
described in Chapter 5 of the statutory guidance document, Working Together to 
Safeguard Children11. The overarching purpose of child death review is to understand 
how and why children die, to put in place interventions to protect other children, and to 
prevent future deaths. Working Together describes two interrelated processes: 
 
i. 
a “Rapid Response” multi-professional investigation of an individual unexpected 
death; and,  
ii. 
a Child Death Overview Panel (CDOP) review of all deaths in a defined geographical 
area. The purpose of the CDOP is to establish the exact cause of death, identify 
patterns of death in community and remedial factors, and to contribute to improved 
forensic intelligence in suspicious deaths. The family should be kept central to the 
process. 
 
Drivers for Change including new Legislation 
15. The review of child deaths has been, to date, far more comprehensive than that for 
adults. However the following drivers for change exist: 
 
i. 
Variation in process. There is significant variation across the system in how child 
deaths are reviewed, which deaths are reviewed, and the quality of the review. 
Specifically: 
 
•  ‘unexpected’ deaths in the community are generally reviewed as per the Sudden 
Unexpected Deaths in Infancy (SUDI)  process. However there is variation in 
when a death is considered “unexpected” and in the timing of triggering 
investigations.  
•  hospital deaths are usually reviewed at a Mortality and Morbidity (M&M) meeting. 
However there is wide variation, across the NHS, in how these meetings are 
convened, no standardisation on terminology, and a confused array of 
investigations (root cause analysis, serious incident inquiry, mortality review) that 
follow certain types of deaths. 
39 
 

•  there is wide variation in CDOP processes (size, structure and functioning) and 
many CDOP panels are dislocated from governance processes within their local 
children’s hospital.  
 
ii. 
The Wood Review12. In 2016, Alan Wood recommended that national responsibility 
for child death reviews should move from the Department for Education to the 
Department of Health, that DH should re-consider how CDOPs should best be 
supported within the new arrangements of the NHS, and that DH  should determine 
how CDOPs might be better configured on a regional basis with sub-regional 
structures to promote learning. He also recommended that child deaths be reviewed 
over a population size that allowed a sufficient number of deaths to be analysed for 
patterns and themes. He went further to recommend that the NHS consider the role 
CDOPs should play in the process for achieving a common national standard for high 
quality serious incident investigations. Finally, he supported the intention to introduce 
a national child mortality database, and urged DH to expedite its introduction.  
 
iii.  The National Adult Case Review programme13. This programme uses a very different 
structured judgment review (SJR) methodology to that used in child mortality review. 
It focuses on problems in heath care processes within an organization rather than 
trying to understand the cause of death. Cases in which care is judged to be poor are 
scored according to an ‘Avoidability of Death’ scale. It is important to recognise that 
many 16 and 17 year olds die in adult ITU’s and therefore it is important to 
understand what processes should take precedence in the review of such patients. 
 
iv.  Medical Examiner process. The Medical Examiner will be introduced across England. 
This appointee will link with  bereaved families as well as the Coroner and their 
involvement will affect all mortality review processes. 
 
v. 
CQC report: Learning, Candour, and Accountability14. This report identified 
inconsistencies in: the involvement of families and carers; the process of identifying 
and reporting the death; how decisions to review or investigate a death was made; 
variation in the quality of reviews and investigations; and variation in the governance 
around processes and questionable demonstration of learning and actions. 
 
vi.  Legislative change (Children and Social Work Bill 2017). The Wood Review 
recommendation that national responsibility for child death reviews should move from 
the Department for Education to the Department of Health is being enacted through 
40 
 

the Children and Social Work Bill 2017. Under the new legislation, local authorities 
and clinical commissioning groups are named as ‘child death review partners’ and 
must make arrangements for the review of each death of a child normally resident in 
the local authority area. They may also, if they consider it appropriate, make 
arrangements for the review of a death in their area of a child not normally resident 
there. The proposed legislation also states that the ‘child death review partners’ must 
make arrangements for the analysis of information about deaths reviewed and 
identify any matters relating to the death or deaths in that area a) relevant to the 
welfare of children in the area or to public health and safety and b) to consider 
whether it would be appropriate for anyone to take action in relation to any matters 
identified.  
 
National Child Mortality Programme 
16. NHS  England is undertaking a national review of child mortality review processes both in 
the hospital and community. A key aim is to make the process easier for families to 
navigate at a very difficult time in their life. Central to the programme is the creation of a 
National Child Mortality Database, which is currently being commissioned. The effective 
functioning of the national database requires high-quality, standardised data arising from 
simplified and standardised local mortality and CDOP review processes. NHS England 
have therefore established 3 work streams: 
 
•  the simplification and standardisation of mortality review processes in the community 
and hospital; 
•  a review of the governance arrangements and standardisation of CDOP processes; 
•  the creation of the national child mortality database. 
 
17. The goals of the NHS  England’s child mortality review programme are to: 
 
•  establish, as far as possible, the cause or causes of each child’s death; 
•  identify any potential contributory or modifiable factors; 
•  provide on-going support to the family; 
•  ensure that all statutory obligations are met; 
•  learn lessons in order to reduce the risk of future child deaths; 
•  establish a robust evidence base to inform national policy across government to 
reduce avoidable child mortality across the UK nations. 
 
41 
 

18. NHS  England, the Department of Health and the Department for Education are working 
together to produce new statutory guidance for child death review. This guidance will 
cover the processes which should take place following the death of a child, and in 
particular how the death should be reviewed at local mortality meeting and child death 
overview panel. This new guidance will be published in late 2017. 
 
Reporting 
19. The definitions used within the adult Case Review programme for record review and to 
identify problems in care are not recognised within Working Together. NHS England’s 
work programme intends to identify best practice and standardise processes across 
deaths in hospital and the community, to improve the experience of families and 
professionals. The deaths of children who are treated in acute, mental health and 
community NHS  Trusts should be included by Trusts in quarterly reporting from April 
2017. The information should come from child death review processes, and should 
include reporting problems related to service delivery.  
 
Board Leadership 
20. Hospital Trust, Local Authority, Community Trust, Mental Health Trusts, and CCG boards 
should ensure that learning is derived from the care provided to children who die, by the 
appropriate application of the child mortality review process, and that learning is shared 
and acted on. 
 
21. Many of the points around board leadership relating to adult deaths (set out in the main 
body of this guidance) also apply for child deaths. For example, providers must ensure 
that they have a board-level leader designated as patient safety director to take 
responsibility for the learning from deaths agenda (Annex A) and he or she should also 
have specific responsibility for the learning from child mortality processes. The director 
should ensure that the reviews are delivered to a high quality, with sufficient numbers of 
trained staff to lead the child mortality review process. 
 
22. Particular attention should be paid to the deaths of children and young people with 
learning disabilities or mental health conditions, as these present with frequent co-
morbidities and are often a more vulnerable group. 
 
23. Providers should acknowledge that an independent investigation (one commissioned 
and delivered entirely separately from the organisation(s) involved in caring for the 
patient) may be required where the integrity of the investigation is likely to be challenged. 
42 
 

Best Practice in responding to Death of a Child who dies under a Trust’s Care 
24. All Trusts should have a policy in place that sets out how they respond to the deaths of 
children who die under their care. In doing this they should be mindful of current 
expectations described within Working Together to Safeguard Children (2015) and of 
NHS  England’s current review of child mortality review processes. New statutory 
guidance on child death review will be published in late 2017.  
 
25. That policy should also set out how Trusts: 
 
•  communicate with bereaved parents and carers. This should include providing an 
honest and compassionate account of the reasons for death and knowledge of any 
potential problems in care that may need further review, ensuring initial contacts are 
managed by clinicians responsible for the care of the patient, and offering support to 
express concerns about the care given to patients who have died;  
•  achieve independence (where relevant) and objectivity in the child mortality review 
process, as well as  lay membership within wider clinical governance systems.  
 
Cross-system Reviews and Investigations 
26. When the death of a child involves treatment across the health care pathway (primary: 
secondary: tertiary care) it is expected that child mortality review processes will not be 
duplicated and that a single overarching meeting will be convened. Child mortality review 
processes should interface with existing organisational governance systems. The NHS 
England child death review programme is mindful of expectations arising from the 
Serious Incident Framework, which sets out the circumstances in which further 
investigation is warranted in certain situations.  It is therefore anticipated that when a 
review identifies a problem in care that meets the definition of a patient safety incident 
(any unintended or unexpected incident which could have or did lead to harm to one or 
more patients receiving NHS care) then this is reported via local risk management 
systems to the National Reporting and Learning System (NRLS).  Regardless of the type 
of review, its findings must form an integral part of and feed into the organisation’s 
clinical governance processes and structures. Review findings should be considered 
alongside other information and data including complaints, clinical audit information, 
patient safety incident reports and other outcomes measures to inform the Trust’s wider 
strategic plans and safety priorities. 
 
 
 
43 
 

Bereaved Families and Carers 
27. Working Together places the family at the heart of its processes. However it is 
recognised that the multitude of investigations that may unfold following a child’s death 
can cause great confusion and distress to parents. The national bereavement group and 
bereavement charities are closely involved with developing NHS England’s child death 
review programme – both in the co-design of systems and public guidance that explains 
processes. 
 
28. The national Child Death Review programme recognises the following principles: 
 
•  bereaved families and carers should be treated as equal partners both in the delivery 
of care and following a bereavement;  
•  bereaved families and carers should receive a high standard of bereavement care, 
including being offered appropriate support;    
•  bereaved families and carers must always receive an honest, caring and sensitive 
response;  
•  bereaved families and carers should receive timely, responsive contact and support 
in all aspects of any review process, with a single point of contact and liaison. 
 
Learning Disabilities and Mental Illness  
29. NHS  England’s National Child Mortality Review programme fully recognises the unique 
challenge in reviewing the deaths of children with learning disabilities and mental health 
disorders. The Programme is working closely with the Learning and Disabilities Mortality 
Review (LeDeR) programme, and also aims to align itself with the Children and Young 
People’s (CYP) Mental Health Programme and Specialised Commissioning particularly 
with regard to deaths in Tier 4 inpatient CAMHS Units. It will  also work closely with the 
National Programme on Suicide in Young People. Going forward, the programme will 
ensure that there are appropriate mechanisms in place to allow data flows to occur 
unencumbered between all these systems and the national Child Mortality Database. 
 
Conclusion 
30. This section highlights the very different circumstances that pertain to the death of a child 
in acute, mental health and community organisations. Although infant and child mortality 
has declined in the UK, these improvements have not been sustained in comparison to 
other European countries. While poverty and inequality have a major impact on child 
mortality, we can nonetheless do much in front line service delivery to improve outcomes 
44 
 

for children, and experiences for both bereaved parents and the professionals who 
deliver care. Sadly, deaths in childhood are often an inevitable consequence of 
congenital malformations, birth events, and long-term conditions or chronic illness. Many, 
however, have preventable factors, and there is therefore an absolute imperative to 
scrutinise all deaths both locally and nationally to ensure that learning always occurs.  
 
31. NHS  England is seeking to address this by establishing a National Child Mortality 
Database to allow analysis and interpretation of child mortality data. The programme will 
also seek to improve, standardise and simplify the processes that follow the death of a 
child. This is predominantly to improve the experience of bereaved parents at such an 
overwhelming time, but also to enable uniformly robust data collection, to ultimately lead 
to a reduction in infant and child mortality in this country.  
 
References 
1.  Viner RM, Hargreaves DS, Coffey C, Patton GC, Wolfe I. Deaths in young people aged 0-24 years 
in the UK compared with the EU15+ countries, 1970-2008: analysis of the WHO Mortality Database.
 
Lancet. 2014 Sep 6;384 (9946):880-92 
2.  Department for Education.  Child Death Reviews - year ending 31st March 2016. Available from: 
https://www.gov.uk/government/statistics/child-death-reviews-year-ending-31-march-2016 
3.  Government HM. Working Together to Safeguard Children. London. Department for Education. 
2013 
4.  RCPCH. State of Child Health. Report 2017 
5.  Wolfe I, Donkin A, Marmot M et al. UK child survival in a European context: recommendations for a 
national countdown collaboration. Archives of Disease in Childhood. 2015 
6.  Office for National Statistics. Child Mortality in England and Wales: 2014; Available from: 
http://www.ons.gov.uk/peoplepopulationand 
community/birthsdeathsandmarriages/deaths/bulletins/childhoodinfantandperinatalmortalityinenglanda
ndwales/2014 
7.   Eurostat.Infant mortality rate (tps00027). 2014. Available from: 
http://ec.europa.eu/eurostat/web/population-demography-migration-projections/deaths-life-
expectancy-data//main-tables 
8.  Roberts J Bell R. Social inequalities in the leading causes of early death a life cause approach. 
2015 
9.   Royal College of Paediatrics and Child Health, National Children’s Bureau. A policy response to the 
report Why Children Die: deaths in infants, children, and young people in the UK (Part B). London. 2014 
10.  Viner RM, Hargreaves DS, Coffey C et al. Deaths in young people aged 0-24 years in the UK 
compared with the 15+ countries. 1970-2008. Analysis of the WHO mortality database. Lancet 2014: 
384(9946): 880-892.\ 
11.  Government HM. Working Together to Safeguard Children. London. Department for Education. A 
guide to inter-agency working to safeguard and promote the welfare of children. 2013  
12. Government HM. Wood Report.  Review of the role and functions of Local Safeguarding Children 
Boards. March 2016 
13. Royal College of Physicians. National Mortality Case Record Review Programme. Oct 2016. 
Available at: https://www.rcplondon.ac.uk/projects/national-mortality-case-record-review-programme 
14. Care Quality Commission. Learning, candour and accountability. 2016. Available at: 
https://www.cqc.org.uk/sites/default/files/20161213-learning-candour-accountability-full-report.pdf  
45 
 

link to page 34 link to page 46 link to page 46 Annex G - Maternity 
1.  In England, maternity care is generally safe and for the majority of women and their babies there 
is a good outcome.  However, when things go wrong, the impact is devastating and has a 
profound effect on the parents, partners, siblings and extended family members.    
 
2.  Dr Bill Kirkup was  tasked by the Secretary of State for Health to investigate and report on 
maternity services at Morecambe Bay NHS  trust.  The Report of the Morecambe Bay 
Investigation in 201520 highlighted a number of failures over a number of years at the 
Trust which resulted in poor care and the tragic deaths of mothers and babies. The 
report makes recommendations for mandatory reporting and investigation of serious 
incidents of maternal deaths, late and intrapartum stillbirths and unexpected neonatal 
deaths. It recommends a requirement that investigation of these incidents be subject to a 
standardised process, which includes input from and feedback to families, and 
independent, multidisciplinary peer review.  In Learning not Blaming 21 the Government 
accepted this recommendation. 
 
3.  In October 2016, Safer maternity care: next steps towards the national maternity 
ambition was published setting out an action plan for the Government’s vision for making 
NHS  maternity services some of the safest in the world, by achieving the national 
ambition to halve the rates of stillbirths, neonatal deaths, brain injuries that occur during 
or soon after birth and maternal deaths, by 2030 with an interim measure of 20% by 
2020.  The plan details the actions needed at national and local level that build on the 
progress already made to improve the safety of maternity services. 
 
4.  Currently MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and 
Confidential Enquires across the UK) 22, appointed by Health Quality Improvement 
Partnership and funded by NHS England, run the national Maternal, Newborn and Infant 
                                                             
20  The report of the Morecambe Bay Investigation (March 2015): 
https://www.gov.uk/government/news/morecambe-bay-investigation-report-published 
21  The government response to the Freedom to Speak Up consultation, the Public Administration 
Select Committee report 'Investigating Clinical Incidents in the NHS', and the Morecambe Bay 
Investigation (July 2015). 
22  'MBRRACE-UK' is the collaboration appointed by the Healthcare Quality Improvement Partnership 
(HQIP) to continue the national programme of work investigating maternal deaths, stillbirths and infant 
deaths, including the Confidential Enquiry into Maternal Deaths (CEMD). The aim of the MBRRACE-
UK programme is to provide robust information to support the delivery of safe, equitable, high quality, 
patient-centred maternal, newborn and infant health services. 
 
46 
 

link to page 46 link to page 47 Clinical Outcomes Review to conduct surveillance of all late fetal losses, stillbirths and 
neonatal deaths, biennial topic-specific confidential enquiries into aspects of stillbirth and 
neonatal death or serious neonatal morbidity and surveillance and confidential enquiries 
of all maternal deaths. 
 
5.  Surveillance reports on stillbirths and neonatal deaths are published annually. Reports 
on maternal deaths are published on a triennial basis, because the number of maternal 
deaths from individual causes is small, and thus three years’ worth of data is required to 
identify consistent lessons learned for future care and to maintain anonymity and 
confidentiality. 
 
6.  A maternal death is defined internationally as a death of a woman during or up to six 
weeks (42 days) after the end of pregnancy (whether the pregnancy ended by 
termination, miscarriage or a birth, or was an ectopic pregnancy) through causes 
associated with, or exacerbated by, pregnancy. Deaths are subdivided on the basis of 
cause into: direct deaths, from pregnancy-specific causes such as preeclampsia; indirect 
deaths, from other medical conditions made worse by pregnancy such as cardiac 
disease; or coincidental deaths, where the cause is considered to be unrelated to 
pregnancy, such as road traffic accidents. Maternal deaths are very rare. The 
MBRRACE-UK  report ‘Saving Lives, Improving Mothers Care highlights that for 2012-14, 
the maternal death rate was 8.5 per 100,000 women. Overall, 24123 women among 
2,341,745 maternities in 2012–14 died during or within 42 days of the end of pregnancy 
in the UK. 
 
7.  Better Births (2016) 24, the report of the NHS England commissioned National Maternity 
Review, set out a five year forward view for improving outcomes of maternity services in 
England. The report highlighted the lack of a standard approach to investigating when 
things wrong during before, during or after labour: Reviews and investigation are 
currently undertaken using different protocols and processes by different organisations. 
The Report recommended there should be a national standardised investigation process 
for when things go wrong, to get to the bottom of what went wrong and why and how 
future services can be improved as a consequence. Work has now begun on the 
development of a Standardised Perinatal Mortality Review Tool that will enable maternity 
                                                             
23  Of these 41 deaths were classified as coincidental 
24  https://www.england.nhs.uk/wp-content/.../02/national-maternity-review-report.pdf 
47 
 

and neonatal services to systematically review and learn from every stillbirth and 
neonatal death in a standardised way. 
 
8.  Maternal deaths, neonatal deaths and stillbirths occurring in acute, mental health and 
community Trusts should be included by Trusts in quarterly reporting from April 2017.  
 
9.  It should be borne in mind that in addition to hospital obstetric units, maternal deaths can 
occur in a local midwifery facility (for example, a local midwifery unit or birth centre) or 
during home births. The definition also covers up to 42 days after the end of pregnancy. 
 
 
 
 
 
 
 
 
 
 
 
48 
 

Annex H - Cross-system Reviews & 
Investigations 
1.  In many circumstances more than one organisation is involved in the care of any patient 
who dies, with the most common combinations being primary care and acute care, 
ambulances services and acute care, or mental health services combined with any of 
these. Case record reviews typically have to rely on the records held by a single 
organisation, but even these records can provide indications of possible problems in 
earlier stages of the patient pathway.  
 
2.  Where possible problems are identified relating to other organisations, it is important the 
relevant organisation is informed, so they can undertake any necessary investigation or 
improvement. Most trusts already have effective systems to notify other organisations  
when concerns are raised via incident reports, and are likely to be able to adapt these to 
address potential problems identified in case record review.    
 
3.  Trusts should consider whether they can routinely arrange joint case record reviews or 
investigations for groups of patients where more than one organisation is routinely 
providing care at the time of death - for example, for older people with dementia and 
frailty receiving frequent input from their GP and from community mental health nurses. 
Commissioners have a role in encouraging appropriate routine collaboration on case 
record review.  
 
4.  Where the provision of care by multiple providers, and particularly the coordination of 
that care, is thought to have potentially contributed to the death of a patient, investing 
the significant resources required to coordinate major and complex investigations must 
be considered. For example, the Serious Incident Framework outlines the principles 
which underpin a serious incident investigation process and the relevant content is set 
out in paragraphs 5 to 10 below. 
 
5.  The organisation that declares the serious incident is responsible for recognising the 
need to alert other providers, commissioners and partner organisations as required in 
order to initiate discussions about subsequent action. 
 
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6.  All organisations and agencies involved should work together to undertake one single 
investigation wherever this is possible and appropriate. Commissioners should help to 
facilitate discussions relating to who is the most appropriate organisation to take 
responsibility for co-ordinating the investigation process. Commissioners themselves 
should provide support in complex circumstances. For example, where no one provider 
organisation is best placed to assume responsibility for co-ordinating an investigation, 
the commissioner may lead this process. If commissioners do not have the capability or 
capacity to manage this type of activity this should be escalated to ensure appropriate 
resources are identified. This may be something to consider escalating through the 
relevant Quality Surveillance Group or through specific review panels and clinical 
networks. This should ensure the cumulative impact of problems with care can be 
resolved. 
 
7.  In some circumstances the local authority or another external body may be responsible 
for managing and co-ordinating an investigation process. Where this is the case, 
providers and commissioners must contribute appropriately and assure themselves that 
problems identified will be addressed.   
 
8.  Often in complex circumstances, separate investigations are completed by the different 
provider organisations. Where this is the case, organisations (providers and 
commissioners and external partners as required) must agree to consider cross 
boundary issues, such as gaps in the services that may lead to problems in care. The 
contributing factors and root causes of any problems identified must be fully explored in 
order to develop effective solutions to prevent recurrence. Those responsible for 
coordinating the investigation must ensure this takes place. This activity should 
culminate in the development of a single investigation report. 
 
9.  To determine oversight of an investigation, the RASCI (Responsible, Accountable, 
Supporting, Consulted, Informed) model supports the identification of a single ‘lead 
commissioner’ with responsibility for managing oversight of serious incidents within a 
particular provider. This means that a provider reports and engages with one single 
commissioning organisation who can then liaise with other commissioners as required. 
This approach is particularly useful where the ‘accountable commissioner’ is 
geographically remote from the provider (and therefore removed from other local 
systems and intelligence networks) and/or where multiple commissioners’ commission 
services from the same provider. It facilitates continuity in the management of serious 
incidents, removes ambiguity and therefore the risk of serious incidents being 
50 
 

overlooked and reduces the likelihood of duplication where there is confusion regarding 
accountability and/or responsibility and general management of the serious incident 
process. 
   
Healthcare Safety Investigation Branch 
10. The Healthcare Safety Investigation Branch (HSIB) will  provide capability at national 
level to offer support and guidance to NHS organisations on investigations, and to 
carry out up to 30 investigations itself per year where there is a deeper learning 
opportunity for the NHS. Through a combination of setting exemplary practice and 
structured support to others, the HSIB is expected to make a decisive difference to the 
NHS,  promoting a culture of learning and a more supportive relationship with patients, 
families and staff. 
 
11. Providers will benefit from the HSIB,  and their expert advice on safety improvement. It 
should mean timely investigations, with a genuine commitment to openness, 
transparency and engagement with staff and patients and their families and carers that 
adopt an ethic of learning and continuous improvement. The HSIB will  contribute 
strongly to the culture change that is needed in the NHS.   
 
 
 
 
 
 
 
 
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Annex I - Roles and Responsibilities  of 
National Bodies and Commissioners   
1.  Each national organisation will have a single lead at executive level who has accountability, 
internally and externally for that organisation’s support of delivering against the national 
programme on learning from deaths. This will include ensuring progress is reported to the 
National Quality Board and ensuring that learning from deaths remains a priority area in 
future developments. A list of the lead roles for each national organisation is at Annex K 
and will  be made available on each organisation’s website. 
 
2.  As the independent regulator of health and social care, the Care Quality Commission 
will  use this national guidance on learning from deaths to guide its monitoring, inspections 
and regulation of services. Inspectors will use new key lines of enquiry in relation to safety 
and governance, set out in the Care Quality Commission’s assessment framework, to 
assess learning from deaths, collect evidence and identify good practice. Where specific 
concerns are identified, the Care Quality Commission can use its powers to take action 
with individual providers and will report its findings of good and poor progress in individual 
inspection reports or national publications to help encourage improvement.  
 
3.  NHS Improvement will continue to provide national guidance for managing serious 
incidents.  Local processes setting out what deaths should be subject to case record 
review will inevitably use a wider definition than deaths that constitute Serious Incidents. 
Equally, when a death clearly meets Serious Incident criteria there is no need for an initial 
stage of case record review to be completed before work to initiate and support a full 
investigation is undertaken. Serious Incident guidance provides the framework upon 
which the Care Quality Commission and commissioners (including CCGs and NHS 
England) will assess the quality of investigations undertaken across the NHS. NHS 
Improvement will,  alongside the Healthcare Safety Investigation Branch and others, 
support implementation of best practice in investigations by Trusts.  
 
4.  As the revised inspection regime of the Care Quality Commission will assess providers’ 
ability to learn from deaths as a key component of high quality care, work to address this 
will be factored into NHS Improvement’s work to support providers in achieving good or 
outstanding Care Quality Commission care ratings. Regional teams will work with 
52 
 

providers, their commissioners and NHS England to identify areas where improvements 
can be made and the strategies which can help deliver the change required. 
 
5.  Nationally, NHS  Improvement commissions (via the Healthcare Quality Improvement 
Partnership) the work of the Royal College of Physicians to develop and roll-out the 
Structured Judgement Review methodology, which will be providing a national training 
programme for acute Trusts to support them to carry out the methodology for adult 
inpatient deaths. 
 
6.  NHS England has a direct commissioning role as well as a role in leading and enabling 
the commissioning system. This national guidance on learning from deaths will guide its 
practice in both of these areas. 
 
7.  The National Institute for Health and Care Excellence (NICE) has produced best 
practice guidelines on the care of the dying, covering adults and children.  These 
guidelines are supported by measurable quality standards that help Trusts demonstrate 
high quality care, and by information for the public describing the care that should be 
expected in the last days of life. 
 
 
 
 
 
 
 
 
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Annex J - Structured Judgement Review 
in Mental Health Trusts 
Background 
1.  Some mental health providers have seen a missed opportunity in not learning more 
widely from deaths by reviewing the safety and quality of care of a wider group of people. 
This is despite research showing that people with mental health problems have greater 
health care needs than the general population and may suffer unnecessarily with 
untreated or poorly managed long-term conditions. 
 
Where Next - Making a Decision on the Review Method 
2.  Since 2014 hospitals in Yorkshire and the Humber have been working together with the AHSN 
Improvement Academy to refine a mortality review method called Structured Mortality Review 
(SJR), a method proposed for all acute hospitals in England. The acute sector methodology 
reviews phases of care appropriate to their settings, such as initial assessment and first 24 
hours, care during a procedure, discharge/end of life care and assessment of care overall. 
Written explicit judgements of care and phase of care scores form the basis of the reviews. 
This now forms the basis of the national acute hospitals mortality review programme. 
 
3.  This methodology and review format was seen as potentially valuable by three regional 
Mental Health trusts and they have individually worked to create phase of care headings 
more appropriate to mental health care, with the support of the Improvement Academy 
and Professor Allen Hutchinson. These three trusts are at different stages of 
implementation. In the early adopter trust the tool was also adapted to include a pen 
picture to enable the reviewer to understand both the life and death of the person, 
considering this fundamental to understanding areas for learning that may include review 
of physical health and lifestyle choices.  In the same trust this approach was used within 
Learning Disability services prior to the introduction of the Learning Disability Review of 
Deaths (LeDeR) programme. In another trust both the mental health care and community 
care facilities have been using the methods. 
 
Introducing the Review Process 
4.  Just as with  the acute services, future reviewers require initial training in how to make 
explicit judgements of the quality and safety of care and how to assess care scores for 
54 
 

each phase of care. Assessments are made of both poor and good care and it is 
common to find that good care is far more frequent than poor care. 
 
5.  One of the findings from introducing the methods into mental health care is that many of 
the reviewers naturally have a focus on the mental health care component of the 
services. But review teams have found that using this review method they also identify 
common long-term conditions such as diabetes and heart disease that do not appear to 
have been well managed. For example, in one hospital it became evident that many 
people had a number of co-existing comorbid/long term conditions, yet it was unclear 
from the records whether or not the person was receiving support and or review from 
primary care and or secondary care services for their physical health. There is value, 
therefore, in also training up review staff who have an understanding of what good care 
looks like in long-term conditions within the context of mental health facilities. 
 
6.  Scoring of the phases of care is a new approach for many clinical staff in mental health 
care (just as has been the case in acute care) and scoring was initially felt to be very 
daunting by some reviewers. Nevertheless, as staff become more confident with its use, 
scoring can often be seen as a natural outcome of their judgements on the level of care 
provided. Some of the hospital teams have set up a mortality-reviewers support group to 
provide peer review and guidance. Feedback of the good care may be shared with both 
the individual staff and the wider teams - this is often well received. Of course, concerns 
also have to be discussed with services to identify areas for improvement. 
 
Where Next 
7.  The use of the structured judgement method often receives very positive feedback from 
staff trained in this methodology and so in one centre SJR is being rolled out for wider 
use to review the quality of care being received whilst people are currently receiving 
services. Looking forward, it has been recognised that whilst services can learn from 
each case, more can be learnt from the aggregation of cases, where patterns of poor 
care and good care emerge.  In one case study that has sought for such patterns it is of 
note that where patterns exist of poorer care, these have been in the main linked to the 
management of physical ill health within mental health and learning disability services.  
 
8.  For further details please contact Allyson Kent xxxxxxx.xxxx@xxx.xxx , or Professor Allen 
Hutchinson xxxxx.xxxxxxxxxx@xxxxxxxxx.xx.xx Yorkshire and The Humber AHSN 
Improvement  Academy. 
55 
 

Annex K - National Leads 
The list below provides the lead role with overall responsibility for the learning from deaths 
programme at relevant national organisations: 
 
•  NHS Improvement - Executive Medical Director 
•  Care Quality Commission - Chief Inspector of Hospitals 
•  Department of Health - Director of Acute Care and Workforce 
•  NHS England - National Medical Director 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
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Annex L - Background  and Links 
Learning Disabilities Mortality Review (LeDeR) programme 
Background is available at http://www.bristol.ac.uk/sps/leder 
 
Quality Accounts 
Background is available at: 
http://www.nhs.uk/aboutNHSChoices/professionals/healthandcareprofessionals/quality-
accounts/Pages/about-quality-accounts.aspx 
 
Healthcare Safety Investigation Branch 
The new Healthcare Investigation Branch (HSIB) will  offer support and guidance to NHS 
organisations on investigations, and carry out certain investigations itself. It is envisaged that 
the HSIB will  be established to: 
 
i. 
generate investigation findings and recommendations which drive action on the 
reduction or prevention of incident recurrence; 
ii. 
conduct investigations and produce reports that patients, families, carers and staff 
value, trust and respect; and, 
iii.  champion good quality investigation across the NHS, and lead on approaches to 
enhance local capability in investigation. 
 
The HSIB will  be hosted by NHS  Improvement and will undertake a small number of 
investigations annually. It will focus on incident types that signal systemic or apparently 
intractable risks in local healthcare systems. The HSIB and the role of Chief Investigator will 
play a crucial part in developing the culture of safety, learning and improvement in the NHS that 
will  be one of the key elements of national policy and cross-system action in the years ahead. 
 
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