This important report, which has wide-ranging implications, can be found here:
Some of the report’s main findings are:
- Many investigations were of poor quality and took too long to complete
- There was a lack of leadership, focus and sufficient time spent in the Trust on carefully reporting and investigating deaths
- There was a lack of family involvement in investigations after a death
- Opportunities for the Trust to learn and improve were missed.
Of the 1,454 deaths recorded at the Trust during this period, 722 were categorised as unexpected by the Trust. Of these 540 were reviewed and 272 unexpected deaths received a significant investigation. The report does not specify how many investigations there should have been, but draws attention to the limited number of deaths that were investigated in different categories.
NHS England has fully accepted the findings of the final report, following a period of review which included an independent verification of the methodology used.