The death of Connor Sparrowhawk in 2013 resulted in the publication of the ‘Mazars Report’ (December 2015). The report uncovered serious concerns regarding systems of mortality review and management at the Southern Health NHS Trust between April 2011 and March 2015.

In response, the Care Quality Commission (CQC) published a report, ‘Learning, candour and accountability; a review of the way NHS trusts review and investigate the deaths of patients in England’ in December 2016. It showed that in some organisations, learning from deaths was not being given sufficient priority and that valuable opportunities for improvements were being missed.

In its review, the CQC made a number of recommendations about how the approach to learning from deaths could be standardised across the NHS. In March 2017, the National Quality Board published the first edition of the ‘National Guidance on Learning from Deaths’, a framework for the NHS on how it could improve identifying, reporting, investigating and learning from deaths in care. One of the key requirements for Trusts was to publish a policy on how it responds to, and learns from, deaths of patients who die under its management and care.

In September 2019 guidance was finally published on the statutory introduction of Medical Examiners. This role will contribute towards quality assurance and help improve the accuracy of death certification, giving the family of the bereaved support and a formal opportunity to raise concerns while ensuring that the period after death is as problem-free as possible. The role will also identify and support local learning processes from a Trust and family perspective

Learning from Deaths

Following the findings of the Care Quality Commission report Learning, candour and accountability: A review of the way NHS trusts review and investigate the deaths of patients in England, the National Quality Board published the first edition of National Guidance on Learning from Deaths for Trusts.

Mortality Review Group

The Mortality Review Group ensures the Trust has appropriate systems for the monitoring and reporting of mortality performance. It ensures that the Board understands the significance and impact of different mortality measures. It also shares the findings and learning from mortality reviews. This is so local practices are clinically effective and safe for patients.

The purpose of the Mortality Review Group is to:

  • assess the implications and impact of national directives on mortality governance and strengthen local arrangements.
  • influence policy and practice in order to ensure that mortality monitoring and review leads to improvement in patience care,
  • assure the Board that mortality review processes are functioning effectively and that clinical staff are aware of their responsibilities in contributing to the process,
  • ensure that variations in mortality performance are acted upon appropriately and proportionately,
  • provide routine reporting on mortality performance internally and externally to the public.

The North East Quality Observatory Service

NEQOS provides and independent quality measurement service for NHS organisations subject to a subscription arrangement.  They provide expert analysis in a range of core and bespoke projects.


Hospital Mortality Monitoring: