for the site to work. We also use non-essential cookies to help us improve our digital services. Any
We want to know how our website is working for you and where we can improve.
These publications identify lessons to be learned from collective analysis of our investigations. Our aim is to encourage a greater focus on learning in order to contribute to improvements in the services we investigate, potentially helping to prevent avoidable deaths and encouraging the resolution of issues that might otherwise lead to future complaints. If you would like to receive Learning Lessons update emails please sign up for our mailing list (on the Contact Us page).