Confidential Inquiry into the deaths of people with learning disabilitiesReviewing deaths Workshop Pauline Heslop Anna 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?