Recommendations are set out in more detail in the report, where the CQC describe what action they recommend and which body should lead it.
In summary, they've identified the need for improvement in the following areas.
- Learning from deaths needs much greater priority within the NHS to avoid missing opportunities to improve care.
- Bereaved relatives and carers must receive an honest and caring response from health and social care providers and the NHS should support their right to be meaningfully involved.
- Healthcare providers should have a consistent approach to identifying and reporting the deaths of people using their services and share this information with other services involved in a patient's care.
- There needs to be a clear approach to support healthcare professionals' decisions to review and/or investigate a death, informed by timely access to information.
- Reviews and investigations need to be high quality and focus on system analysis rather than individual errors. Staff should have specialist training and protected time to undertake investigations.
- Greater clarity is needed to support agencies working together to investigate deaths and to identify improvements needed across services and commissioning.
- Learning from reviews and investigations needs to be better disseminated across trusts and other health and social care agencies, ensuring that appropriate actions are implemented and reviewed.
- More work is needed to ensure the deaths of people with a mental health or learning disability diagnosis receive the attention they need.