This programme has now closed but you may find the below resources useful. Please note the information on this webpage was correct at the time of publication:

The West of England AHSN in collaboration with eight acute trusts were one of the early implementers of the structured review and have developed a best practice framework to support trusts in adopting the Royal College of Physicians’ (RCP) National Mortality Case Record Review Programme.

All acute trusts have systems in place to ensure patient safety and quality of care. Many of these include ways of reviewing hospital deaths, often by detailed review of the case notes, to identify areas that could be improved. However, until this project (in 2016 and 2017) there was no standardised approach to reviewing deaths and reviews have been limited to deaths occurring in the hospital setting.

The Royal College of Physicians in partnership with the Yorkshire and Humber AHSN Improvement Academy and Datix have developed a standardised approach and in the West of England were early adopters.

‘Together, we aim to ensure that a system which reviews all deaths of elective patients and a proportion of those admitted as an emergency is established by all acute hospital trusts in the West of England, so that learning from such reviews, results, as appropriate, in improved health services delivery’.

Christine Teller, a public contributor involved in the project.

The roll-out was delivered in two phases, with the Cohort 1 Trusts trained in October 2016 with the remaining trusts receiving their training in summer 2017. For latest information on the national programme please visit the Royal College of Physicians website.


ReSPECT stands for Recommended Summary Plan for Emergency Care and Treatment. ReSPECT is about creating a personalised recommendation for someone’s clinical care in emergency situations where they are not able to make decisions or express their wishes. Our focus on ReSPECT evolved from our work on Structured Mortality Reviews and the national Learning from Deaths programme which highlighted the need for appropriate care planning as patients approach the end of their life. Read more about ReSPECT.

Useful resources

Please note that the documents available for download below were current at the time of training in 2016 and 2017. 

Useful resources generated through the West of England mortality reviews collaborative:

Useful resources generated through the National Quality Board: 

It has been acknowledged that the NHS can improve the way we engage with families and carers when things go wrong and as part of the national Learning from Deaths programme the National Quality Board has released guidance for trusts on working with bereaved families.  The guidance advises trusts on how they should support, communicate and engage with families following a death of someone in their care.

Recognising that families will also need some help and guidance at what can be a very difficult and distressing time, this template can be used for trusts to generate a local leaflet which gives the family practical advice, support and information following the death of someone close to them.

Learning and sharing

Previous events