Confidential Inquiry into the deaths of people with learning disabilities

Reviewing deaths Workshop

Pauline HeslopAnna Marriott

Reviewing deaths

• The aim must be to identify factors that can be changed that will lead to improved heath and health care for people with learning disabilities.

Review stages

•Notification

•Collection of core data

•Interviews

•Reviews of records

•Local Review Panel meeting

•External scrutiny

Replicating the approach

• Single agency reviews without external scrutiny.

• Single agency reviews with external scrutiny.

• Multi-agency reviews without external scrutiny.

• Multi-agency reviews with external scrutiny.

Practice issues• Engaging with

professionals

• Encouraging participation

• Emphasis on reflective learning

• Making a difference• Mike’s story.

Policy issues

• Code of conduct

• Permissions and approvals

• Data protection

• Security

• Confidentiality.

Potential impact

• Higher threshold for reporting patient safety incidents.

• More confidence to challenge poor quality care.

• Increased knowledge about potential contributory factors.

• Reflect – is care equitable and have reasonable adjustments been made?

The way forward?