NHS England is currently reviewing the National Health Service Serious Incident Framework. This describes the principles and procedures that all organisations providing, commissioning or overseeing NHS-funded care should follow when responding to Serious Incidents. Serious Incidents by definition include all unexpected or avoidable deaths in NHS-funded care. The revised Framework will provide up to date guidance on the appropriate response to such deaths, including how investigations should be carried out and quality assured to deliver learning and improvement of services.

The current Framework is available at:

www.england.nhs.uk/wp-content/uploads/2013/03/sif-guide.pdf

NHS England is also working on plans for a Root Cause Analysis (RCA) Investigation academy to drive good practice in the use of RCA investigation, ensuring its full potential is harnessed in order to inform learning and measurable patient safety improvement.

In addition reforms to the process of death certification and the coroner service, including the appointment of a Chief Coroner, will help identify appropriate cases for referral to the coroner for further investigation as well as benefiting bereaved families across England and Wales by creating more effective coroners services.

NHS England’s existing Serious Incident Framework makes clear the importance of full co-operation of National Health Service organisations with any external investigations of serious

incidents, which include unexpected or avoidable deaths, including police investigations. The Framework states that “Providers should.. .collaborate with external scrutiny of investigations and any remedial work required following investigations, including full and open exchange of information with other investigatory agencies such as the police, Health & Safety Executive, Coroner and local safeguarding boards.

In addition, we expect all healthcare professionals to bear in mind their professional codes of conduct when asked to co-operate with any police investigations into patient deaths in hospitals. The professional code of conduct for registered nurses and midwives, for example, states that You must cooperate with internal and external investigations.../. This is important in order for NHS staff to remain accountable and provide the best patient care.