Intended for healthcare professionals


Investigating avoidable patient deaths

BMJ 2017; 356 doi: (Published 19 January 2017) Cite this as: BMJ 2017;356:j223

This article has a correction. Please see:

  1. Margaret Murphy, external lead adviser1
  1. 1WHO Patients for Patient Safety Programme, Geneva, Switzerland
  1. margaretmurphyireland{at}

Families must come first, not corporate damage limitation

The Care Quality Commission’s (CQC) review of the way in which NHS trusts review and investigate the deaths of patients in England makes for sobering reading.1 It emphasises that learning from deaths needs to be given much greater priority within the NHS to avoid missing opportunities to improve care.1

The review also found that no trust had good practice across all aspects of identifying, reviewing, and investigating deaths and ensuring that learning is implemented, but that some trusts showed promising practice at individual steps.1 This comes as a welcome affirmation for patients and families, and as a validation of how they have, all too often, described their unsatisfactory experiences of interactions with healthcare services and professionals in the aftermath of adverse events.2 The experiences of the World Health Organization’s Patients for Patient Safety cohort, representative of over 50 countries, are testament to the …

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