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Introduction

In response to the publication of the Learning from Deaths quality standard 2017 Ashford and St. Peter’s Hospital NHS Foundation Trust has revised the current mortality review process to align with national requirements. The CQC report Duty, Learning and Candour² outlined the case for change to build standardisation and uniformity into the mortality process locally and nationally. Greater emphasis should be placed on independent review of all deaths, to promote objectivity and external scrutiny, with improved engagement with bereaved families/carers to ensure learning from deaths enables and informs quality improvements.

Central to the delivery of our quality objectives is being able to demonstrate that we are a learning organisation. Learning from deaths is important to the trust and resonates with our values of putting patients first, including families and carers.

It is important to the trust that when things do not go as planned resulting in poor outcomes for patients, that we can identify those problems early to be able to understand how and why they occurred, so that we may take meaningful action in order to prevent recurrence.

Retrospective case note reviews will help to identify examples where processes can be improved and gain an understanding of the care delivered to those whose death is expected and inevitable to ensure they receive optimal end of life care.

This standardised Trust-wide process integrating mortality reviews into the governance framework will provide greater levels of assurance to the Trust Board and help to ensure that the organisation is using mortality rates and indicators alongside others such as incidents and complaints to monitor the quality of care and share good practice and learning from mistakes. This document sets out how the Trust will learn from deaths that occur which were unexpected. This is in response to the National Guidance on Learning from Deaths (published March 2017).

The policy makes clear the procedure for responding to and learning from patient deaths across the Trust including:

  • When and how the death of a patient should be reported.
  • How deaths should be reviewed and investigated by the Trust.
  • How the organisation should engage with bereaved families and carers.
  • How the Trust learns from deaths to improve and inform clinical practice.

This document complements other Trust policies which are also concerned with the reporting, investigating and learning from incidents.

 

Policy Details

Download: PDF version
Compiled by: Melanie Irvin-Sellars, Divisional Director for Medicine
Ratified by: Mortality Review Group
Date Ratified: Oct 2017
Date Issued: Nov 2017
Review Date: Oct 2020
Target Audience: All staff and public
Contact name: Marty Williams