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A flexible system to support Learning Disabilities Mortality Reviews


Learning Disabilities Mortality Reviews

A Learning Disabilities Mortality Review (LeDeR) is conducted in the unfortunate circumstance that a death of a person with learning disabilities occurs. An Initial Review must take place in the first instance, should the Initial Review raise concerns about the care of the person who died or highlight where vital learning could be gained, a further review will then be led. The detailed review relies on multi-agency collaboration and engagement, to determine the lessons and recommendations that must be taken, and identify actions that will improve knowledge, services and care of people with learning disabilities.

A 2019 University of Bristol annual report showed a disproportionate number of treatable causes of death in people with learning disabilities (403 per 100,000) than those in the general public (83 per 100,000). This indicates a grave importance for deriving lessons and implementing actions as a result of the LeDeR process, to ensure the continuous improvement of the service and care provided to those with learning disabilities and significantly reduce premature, preventable deaths.

The review process can often-times rely heavily on administrative, manual tasks due to the nature of the multi-agency involvement. Time intensive tasks include distributing, chasing and consolidating agency forms, organising meetings, assigning and tracking progress of actions and collating feedback from the end report to name just some aspects of the manual, resource intensive process.

In addition, when collecting data and responses from agency partners, the information is more often than not spread out across different emails, word documents, spreadsheets and even various paper documents too. Not only does this weigh heavily on time resources, but information being stored in emails and across paperwork also compromises the security of what is incredibly sensitive data.

QES Case Review System

The Case Review system is part of QES’ Holistix Safeguarding Suite enabling local, regional and national safeguarding teams to collect, interpret and gain value from multi-agency information, in order to continuously improve the safeguarding of children and vulnerable adults. This is not just an opportunity to understand where there are problems, but to enforce change and prevent potentially avoidable and often tragic incidents from taking place again.

The system has been built across a wide range of applications to meet the requirements of various case review processes; with national guidance, terminology, forms and statutory timings altered depending on the application i.e. reflecting the NHS England LeDeR Programme format. QES are committed to evolving the system to reflect new national guidance, and continuously learning from our ever-growing user group and by attending relevant conferences and webinars.

Features Overview

Below is a brief overview of some of the Case Review features:

  • Intuitive and easy to navigate system including user-friendly interface, compatibility across multiple devices, personalised dashboards and more


  • Initial notification and agency involvement forms are securely completed on the system, with an automatic form consolidation feature combining all details to display a comprehensive view of circumstances provided by multiple agencies in one centralised location


  • Meeting management feature supports initial organisation, managing attendance and the distributing of key information surrounding meetings (i.e. agenda, minutes, supporting documents, as well as lessons and recommendations determined from a meeting)


  • Lessons, recommendations and themes are recorded, updated and available for reporting within the system. The heart of the Case Review system is to identify learning, with a multi-agency input, to ensure safeguarding practices are constantly evolving


  • Action tracking and planning feature enables users to assign actions against people, link them to lessons and recommendations, establish deadline dates and monitor progress, ensuring there is an element of accountability involved in implementing changes to improve safeguarding processes


  • Automated chronology feature orders an unlimited number of multiple agencies’ timeline of events into chronological order, with the ability to filter by agency, user, significance and date range


  • Independent Author reports are accessible on the system with a comments facility alongside and the ability to share with team members. This enables collective input which facilitates the completion of the document to its best standard, at which point a publicly available link to the form is created for publication


  • Comprehensive real-time reporting dashboard gives a visual representation of real-time statistics on common themes, lessons learnt, agency involvement and lots more. This allows safeguarding partnerships to react to emerging issues more quickly and identify where improvements must be made


  • Secure and GDPR compliant with two-factor authentication code, no sensitive data leaving the system, and multiple user roles ensuring information is only seen by those with granted access permissions

Download in PDF format

To receive full information on the Case Review system, or to arrange a demonstration, contact us today here.

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