The NHS is the world’s first health organisation to publish data on avoidable deaths. The National Guidance on Learning from Deaths has driven a strengthening of systems of mortality case review with emphasis on learning. By collecting the data and taking action in response to failings in care, trusts will be able to give an open and honest account of the circumstances leading to a death. This National Conference focuses on improving the investigation and learning from deaths in NHS Trusts following the National CQC and NQB guidance, and Department of Health reporting requirements.The conference will also discuss the role of Medical Examiners which were introduced in April 2019, providing a national system of medical examiners will be introduced to provide much-needed support for bereaved families and to improve patient safety. Attendance at this conference will support you to:Network with colleagues who are working to improve practice in the investigation and learning from deathsLearning from the National Mortality Case Review ProgrammeReflect on the lived experience of a carer Learn from working examples of mortality governance and develop the role of mortality audits, internal inspection and mortality reviews to answer the question “did a problem in care contribute to the death?Understand national developments and national reporting requirementsLearn from best practice in the investigation of deathsIdentification and reporting of deaths and the role of the Medical ExaminerImproving your processes and skills in mortality review and mortality governanceReflect on how you improving involvement of families and carersUnderstand the decision to investigate, and the appropriate level of investigationImproving your skills in serious Incident Investigation: applying the serious incident framework and using skilled analysis to move the focus of investigation from acts or omissions of staff, to identifying the underlying causes of the incidentImplementing and integrating a Learning from Deaths dashboardSelf assess your learning from deaths process and ensure investigations lead to changeGain CPD accreditation points contributing to professional development and revalidation evidence