The Care Quality Commission's review Learning, candour and accountability highlights there are wide variations in how patient deaths are investigated.
We have a leadership role for patient safety in the NHS and provide support to identify, understand and manage risks to the safety of patients, not least via routine review of patient safety incident reports sent to the National Reporting and Learning System.
We already work alongside NHS providers to help spot emerging issues, or areas for improvement, by setting guidelines.
The NHS works tirelessly to deliver safe, high quality, care to patients across the country. However this report makes it clear that the whole system must do better when learning from care provided to people who die. We now need to work together to develop solutions to support the NHS to learn from patient deaths so it can continue to improve the quality of care it delivers.
This report also highlights that too often families of those who have died have been let down by the NHS. For that, we are sorry. More needs to be done to make sure they are properly treated and supported during these investigations, especially for the families and carers of patients who had learning disabilities or mental health conditions.
This is an opportunity for us to see where we can focus our efforts to help the NHS put learning at the heart of its practice and demonstrate a global standard of excellence.
Mike Durkin, NHS Improvement's National Director of Patient Safety
We'll work closely with the Care Quality Commission, Department of Health, and our partners to examine these findings and develop a clear approach to how we will support the NHS to identify, report, investigate and learn from patient deaths.