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Statement on the publication of the report into how we involve families in investigations following a death

Today we have published a report into how we involve families in investigations following the death of someone under our care. This was commissioned as part of our commitment to improve the way we conduct investigations following the death of an individual in contact with our services. The report was written by an independent author, Stephany Carolan - director of Carolan Consultants and a work psychologist and researcher. 

Julie Dawes, Interim Chief Executive, commented:

“This report makes very difficult reading for us. We knew this would be the case when we commissioned it but we also knew this collaborative approach would be a crucial part of our learning curve.

“We are very grateful to the families who took part in this report. Their input, talking openly about a very painful part of their lives, cannot be underestimated and these first-hand accounts will help us to get better at considering and involving families in the future. And not just when the death of a loved one is being investigated, but also during a loved one’s ongoing care and treatment. No longer can family involvement simply be seen as an act of courtesy – family involvement is critical to helping us deliver the best quality of care.

“I want to personally apologise for the distress our investigation processes may have caused in the past. We know we need to improve and we are committed to doing things better. Since last year’s Mazars report, we have already made a number of changes to how we investigate deaths. However, today’s report provides us with additional recommendations, based on the all-important input of families, and we shall be carefully digesting and incorporating these latest findings into our existing improvement plan.

“We want to be open and transparent in what we are doing to improve. To this end, we will be sharing an update of our action plan six months from now with the twelve families who gave up their time to help us improve.”


Contact the Communication Team on tel: 023 8087 4666 or via email: for further information.

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