The report provides helpful insight into the system-level and local challenges to effective investigations, greater candour and transparency, and learning from deaths across the NHS. Overall, the review found that:

• Families and carers often reported a poor experience of investigations and felt they were not always treated with kindness, respect and honesty, especially for people in mental health or learning disabilities services.
• There is no single framework for NHS trusts that sets out the approach to learning from deaths, which means there is wide variation in systems and processes in place locally. As a result, learning from deaths is not being considered appropriately in the NHS and opportunities to improve care for future patients are being missed.
• There are trusts that demonstrate elements of promising practice at individual steps in the investigation pathway, but none that could demonstrate good practice across all aspects of identifying, reviewing and investigating deaths and ensuring that learning is implemented