Learning, candour and accountability: A review of the way NHS Trusts review and investigate the deaths of patients in England

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76 p.

<span style="font-size: 10pt;">NHS England's commissioned review looked at all mental health and learning disability deaths at Southern Health NHS Foundation Trust between April 2011 and March 2015. The report identified a number of failings in the way the trust recorded and investigated deaths and highlighted that certain groups of patients including people with a learning disability and older people receiving mental health care were far less likely to have their deaths investigated by the trust. The Secretary of State for Health asked us to look at how acute, community and mental health NHS trusts across the country investigate and learn from deaths to find out whether opportunities for prevention of death have been missed, and identify any improvements that are needed.</span>