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Mortality Reviews

In accordance with National Quality Board guidance, from October 2017 the Trust will start to report information on the total number of deaths, deaths for people with Learning Disability and whether any deaths were avoidable.

How cases are selected for review?

When deaths occur within the Trust they are screened and/or undergo case review. The following deaths are reviewed using a detailed case review approach:

  • All deaths where bereaved families and carers, or staff, have raised a significant concern about the quality of care provision at the time of death.
  • All inpatient, out-patient and community deaths of a person with learning disabilities. This review is forwarded to be part of the LeDeR process which sits within the CCG.
  • All inpatient, out-patient and community deaths of people who have been in contact with our Mental Health Services in past 12 months.
  • All inpatient, out-patient and community deaths of children via the Child Death Overview Panel (CDOP).
  • All maternal (up to one year post partum) and neonatal deaths.
  • All deaths after an elective procedure.
  • All deaths in Intensive care Unit.
  • All deaths where a more in-depth review is justified after applying an initial screening process and where there are concerns about the quality of care they received. This occurs for adult inpatient deaths, ED deaths, community deaths and deaths that occurred while under the care of the Ambulance service.

The Trust is using the Royal College of Physicians (RCP) Structured Judgement Review (SJR) to case review all inpatient & ED deaths when required; a similar tool is being used by the Mental Health Services. Other nationally accepted case review approaches are used in other services.

How are families and carers supported?

All family and carers will be treated with care and compassion before, during and after the death of their loved one while under the care of the Trust. This will be provided by Trust frontline staff, the Bereavement Office and Hospital Palliative Care Team and the End of life Care Facilitator, when they have been involved.

How are staff supported?

Our staff similarly have access to support while caring for people who are dying while under the care of the Trust. This can be accessed from the End of Life Care Facilitator and Hospital Palliative Care Team as well as from their direct line managers. Referral to Occupational Health for ongoing support can also be arranged when necessary.

How is learning generated and fed into governance and improvement processes

The outcomes from screening and case review are monitored by the Mortality Review Group which is led by the Trust Medical Director. Learning is shared from this group across the Trust. Reports from this group also inform our Trust quality groups and the Trust Board.

How does the Board take ownership and publish relevant board level information?

The Trust Board receive a quarterly report from the Trust Mortality Group which looks at a range of data and includes the summary of the local reviews and outcomes as well as nationally collated data summaries such as those published by Dr Foster. Data from the quarterly reviews are published as part of the Trust’s commitment to openness.   The reports are published with the Trust Board papers and as separate reports.


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