Confidential Inquiry into the deaths of people with learning disabilities Reviewing 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 Mikes 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?