A CQC review in December 2016, 'Learning, candour and accountability: a review of the way trusts review and investigate the deaths of patients in England’ found that some Trusts do not focus on the opportunity to learn and improve from deaths.        

In March 2017, the National Quality Board published its 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.

Gloucestershire Care Services NHS Trust (GCS) has for a number of years been undertaking learning from deaths through a process that has evolved to match the expectations of the organisation in delivering high quality care, and also to comply with national guidance.

The Trust’s Learning from Deaths policy is available here - it incorporates the MIDAS process, the pilot Medical examiner service and involvement of the bereaved, improve the quality of the care they provide to patients and their families, and identify where the Trust could do more.