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This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. There will be an extended focus on engaging and involving patients, families and staff following a death, and on learning from deaths including an update from a coroner.
By 2024, all deaths in the community or acute settings that do not required to be referred to the coroner (non-coronial deaths) will need to be scrutinised by a medical examiner.
The conference will discuss the role of Medical Examiners in learning from deaths which is now being extended to all non-coronial deaths wherever they occur. The conference will also include a split stream where delegates can chose to focus on investigating and learning from either deaths in acute care, or deaths in primary and community care.
The conference will also update delegates on the New National Patient Safety Incident Response Framework which was published on 16th August 2022 and the implications for serious incident investigation and learning from deaths.
“A new statutory medical examiner system is being rolled out across England and Wales to provide independent scrutiny of deaths, and to give bereaved people a voice. From 9 September 2024 all deaths in any health setting that are not investigated by a coroner will be reviewed by NHS medical examiners. The changes, which form part of the Department of Health’s Death Certification Reforms, were announced by the government on 15 April 2024, and come into force on 9 September 2024.”
NHS England June 2024
“Medical examiners will look at causes of all deaths not investigated by the coroner to help prevent criminal activity and poor practice… Medical examiners will strengthen safeguards by scrutinising how people have died prior to registration and make sure the right deaths are referred to coroners.”
Department of Health and Social Care 14th December 2023
“The move to a statutory system in 2024 will further strengthen those safeguards, ensuring that all deaths are reviewed and the voices of all bereaved people are heard.”
Dr Suzy Lishman, Senior Medical Adviser on Medical Examiners for the Royal College of Pathologists 14th December 2023
Attendance at this conference will support you to:
Network with colleagues who are working to improve practice in the investigation and learning from deaths
Improve practice in learning from deaths
Reflect on the involvement of families through a lived experience of a carer
Learn from working examples of mortality governance and develop the role of mortality audits, internal inspection and mortality reviews to answer the question “did a problem in care contribute to the death?
Implement the new Patient Safety Incident Response Framework and improve learning from serious incidents
Understand national developments and national reporting requirements
Learn from best practice in the investigation of deaths
Identification and reporting of deaths and the role of the Medical Examiner – including extending this role to all non-coronial deaths
Improving your processes and skills in mortality review and mortality governance
Reflect on the Coroner perspective and role
Understand the decision to investigate, and the appropriate level of investigation
Explore how a human factors can support learning from deaths
Effectively support staff when a death occurs including supporting staff through coroner inquests and serious incident investigations
Self assess your learning from deaths process and ensure investigations lead to change
Supports CPD professional development and acts as revalidation evidence. This course provides 5 Hrs training for CPD subject to peer group approval for revalidation purposes
