#WeNurses - Thursday 30th January 2020 8pm (GMT Standard Time) Learning from Deaths

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 Chat Details


Hosted by WeNurses using #WeNurses

This chat is guest hosted by @smillichope @HeatherStacey7

Gosport / Education aspects

Learning from Deaths


Stephanie Millichope "I am a specialist community public health nurse and have been in nursing for 22 years.  My career is focused on patient safety, experience and quality of care having worked in acute and community provider settings, CCGs and NHS England.  I am currently a patient safety fellow funded by Health Education England and hosted by the Kent Academic Health Science Network. A colleague and I based in Dorset have been asked to look at the educational aspects of the Gosport Independent Inquiry published in 2018 and complete a year-long project in relation to learning from deaths."

Heather Stacey  " I trained as an Occupational Therapist in London over 25 years ago and since then have worked in Oxford, Edinburgh andDorset in a variety of clinical settings within the NHS. I specialised in mental health and completed my Masters in Advanced Mental Health. Since April 2019, I have been in the role of Patient Safety Fellow. This post is funded by Health Education England and is a national role to look at the Learning from Deaths post the Gosport Independent Inquiry."

The Gosport Review was published following an investigation into the use of diamorphine and syringe drivers at the Gosport War Memorial Hospital.  Concerns were raised as early as 1991 by nursing staff stating consideration was not being given for the use of milder sedatives. The report concluded that as many as 650 people had their lives shortened while in hospital. 


Themes from Gosport included

o  Lack of robust prescribing guidelines with patterns of anticipatory prescribing that became the norm at the hospital

o  Judgements/decisions were often not justified clinically and did not consider patients’ or families’ views

o  Family voice not heard – seen as “trouble-makers”

o  Cross system working a challenge - disparate organisations involved and not communicating

o  Staff training/supervision not in place

o  Culture of blame/defensiveness/denial

o  Frontline staff not listened to

o  Systemic problems not recognised.


In relation to the above themes and as part of our learning from deaths project, we have had over 70 conversations with staff of different grades, backgrounds and professions.  Our focus is on what helps staff communicate with patients and relatives as well as other clinicians, both internally and externally around the time of death.  We have also asked about what enables staff to learn and what are the potential barriers. 

We would like our Twitter chat to focus 2 key themes from the project which are communication and staff well-being and resilience.

  1. What do you think helps staff talk about death and dying with patients?
  2. What do you think helps staff communicate with bereaved families/carers/friends?
  3. Tell us about what helped you develop or learn skills to talk about death and dying with patients and their families/carers.
  4. What support do you receive at work when there is a death?
  5. How does resilience relate to your ability to care for patients/families and carers around the time of death?


Useful links

The Gosport Independent Panel 2018


National Quality Board Guidance - Learning from deaths: Guidance for NHS trusts on working withbereaved families and carers 2018


Health Education England – Learning from Deaths E Learning


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