Learning from Patient Deaths in the NHS

The independent regulator of health and social care in England, the Care Quality Commission (CQC) has just published a report on how the National Health Service (NHS) is progressing in the first year of implementing national guidance on learning from deaths.

The report follows on from another published in 2016 which detailed major failings and concerns about the way the NHS investigate and learn from the deaths of patients in their care. The 2019 report contains several case studies which detail experiences of implementing the national guidance.

This report comes more than two years on from the first report and unfortunately the CQC is still seeing the same poor issues previously identified persist. Some hospitals are struggling with involvement and engagement with bereaved families and carers:

“Issues such as fear of engaging with bereaved families, lack of staff training, and concerns about repercussions on professional careers, suggest that problems with the culture of organizations may be holding people back from making the progress needed.” (p4)

In the forward to the 2019 report, Professor Ted Baker, the Chief Inspector of Hospitals states that organizations need to engage with families and carers and to be open with each other. There is a need to share information and learning and not to perpetuate a culture of blame. He recognizes that cultural change is not easy and that it will take some time. However, he states that the current pace of change needs to quicken, it’s not fast enough.

The report found that awareness of the national guidance was high, but implementation was variable. The CQC saw evidence of ad hoc engagement with families and carers but where contact had only taken place after a serious incident or complaint. Creating an open and transparent culture where people feel able to speak up without fear of retribution against them is key. The CQC also saw some examples of positive engagement.

Good practice

The CQC in the 2019 report provide some enablers and barriers to good practice in implementing the national guidance:

  • values and behaviors that encourage engagement with families and carers
  • clear and consistent leadership and governance
  • a positive, open and learning culture
  • staff with the resources, training and support
  • positive working relationships with other organizations (p9)

These themes are not new and have consistently appeared in reports dealing with patient safety and health quality over many years.


There has been an NHS learning curve of a least nearly 20 years in trying and get matters right in NHS patient safety since at least 2000 when the, “An organization with a memory,” the seminal NHS report on patient safety was published. We see however today the same patient safety problems arising. This report shows a promising finding with more awareness of the guidance relating to investigations concerning deaths of patients. Worryingly, however, is that the investigative process problems identified in 2016 are still besetting some NHS organizations.

John Tingle

John Tingle

John Tingle is a regular contributor to the Bill of Health blog. I am a Lecturer in Law, Birmingham Law School, University of Birmingham, UK; and a Visiting Professor of Law, Loyola University Chicago, School of Law. I was a Visiting Scholar at Harvard Law School in November 2018 and formerly Associate Professor at Nottingham Law School, Nottingham Trent University in the UK. I have a fortnightly magazine column in the British Journal of Nursing where I focus on patient safety and the legal aspects of nursing and medicine. I have published over 500 articles and a number of leading texts in patient safety and nursing law. My current research interests are in global patient safety, policy and practice, particularly in African health care systems. My most recent publication is: "Global Patient-Safety Law Policy and Practice," edited by John Tingle, Clayton O'Neill, and Morgan Shimwell, Routledge 2018.

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