Wessex AHSN is helping organisations across Wessex to learn from deaths of people in their care, helping NHS organisations to improve the quality of the care they provide to patients and their families, and identify where they could do more.
A CQC review in December 2016, 'Learning, candour and accountability: a review of the way trusts review and investigate the deaths of patients in England' found some providers were not giving learning from deaths sufficient priority and so were missing valuable opportunities to identify and make improvements in quality of care.
In March 2017, the National Quality Board (NQB) introduced new guidance for NHS providers on how they should learn from the deaths of people in their care. We are now helping trusts to meet the requirements of the new guidance. The full NQB guidance can be downloaded from the resources zone on the right of this webpage.
Following this, the NQB also produced a document to support Bereaved
Families in July 2018 to share good practice for staff. This is also available
on the resources zone . Part of the work of the Patient Safety Collaborative is
to support a Patient Safety Fellow who is looking at this Guidance to
understand nationally how well this has been adopted and how much families have
been involved with this and their experiences of it.
From April 2019 a new medical examiner led system will begin to be rolled out within hospitals in England and Wales. The non-statutory system will introduce a new level of scrutiny whereby all deaths will be subject to either a medical examiner’s scrutiny or a coroner’s investigation. Further information about the system can be found on the British Medical Association website
Wessex Medical Examiners Collaborative
Further to the guidance on Learning from Deaths issued by the National Quality Board in March 2017, and with the advent of Medical Examiners coming on line from April 2019, Wessex PSC has committed to support the establishment of a regional Medical Examiners Collaborative (MEC).
The aim of the Wessex MEC is for member organisations and their patient/carer partners to work together to develop a pan Wessex approach through genuine recognition that so many of our patients experience care across/between pathways and span organisational boundaries.
Notwithstanding the focus on STPs and reconfiguration the Wessex MEC will look at ways in which collaborative working could lead to improvements in learning and facilitate changes of practice / process.
The MEC will also work towards understanding of, and compliance with, national guidance relating to Learning from Deaths, Medical Examiners and care and support for bereaved families and carers.
Membership of the MEC includes NHS Provider organisations across Wessex, GPs, Commissioning Groups and NHSE with representatives from local STP/ICSs as well as members of Wessex PSC.
National Mortality Case Record Review: Annual report 2018
The National Mortality Case Record Review's 2018 annual report is intended to be of general interest to all healthcare professionals but is specifically aimed at those who are responsible for quality improvement within healthcare in addition to patient groups and healthcare users.
More information about the National Mortality Case Record Review Programme, patient safety legacy and new areas of interest can be found on the NMCRR Programme website and the annual report can also be downloaded from the resource zone on the right hand side of this webpage.
Learning from Deaths guidance and resources
NHS Improvement
The NHS Improvement website Learning from deaths in the NHS includes information and resources relating to:
NHS England
The NHS England Medical Examiners website includes information about the Learning Disabilities mortality review (LeDeR)
People with a
learning disability, autism or both often have poorer physical and mental
health than other people and LeDer is designed to help understand why.
To help this programme make the most difference the LeDeR programme needs to know about as many deaths of people with a learning disability, autism or both as possible. The NHSE website includes an online reporting form which anyone can use to report the death of anyone with a learning disability and/or autism
Royal College of Physicians (RCP)
Mortality toolkit: Implementing structured judgement reviews for improvement
The National Mortality Case Record Review (NMCRR) toolkit has been developed to support trusts in implementing a standardised way of reviewing the case records of adults who have died in acute hospitals across England and Scotland.
The Mortality toolkit (SJR methodology) can be downloaded from the resources zone on the right of this webpage.
The National Mortality Case Record Review (NMCRR) programme aims to improve understanding and learning about problems and processes in healthcare associated with mortality, and also to share best practice.
The programme resources on the site include the Mortality toolkit (SJR methodology), data collection form and guide for reviewers plus information about the development of the methodology, experience of the pilots and trainer contact lists.
Yorkshire & Humber Improvement Academy
It is nationally recognised that there are major limitations to hospital mortality statistics and how these can be interpreted. The principal method of retrospectively assessing the safety and quality of care received is retrospective case note review. Therefore, to better understand and learn from hospital deaths a standardised process of mortality case note review is required.
YHIA have been working with acute, community and mental health trusts in Yorkshire & the Humber since 2014 to develop a systematic, evidence-based mortality review programme to drive improvement in the quality and safety of patient care.
The structured judgement case note review method (SJR) they developed is a methodology that allows trained reviewers to identify and describe the quality of care received and in doing so create a score of that quality.
Since 2016 YHIA have been working in partnership with the Royal College of Physicians to deliver the national programme and further information and resources can be found on the YHIA website.
If you have any
questions about the Wessex Patient Safety Collaborative's Learning from Deaths work
or any other aspects of the Wessex PSC, please contact us via email heather.stacey@wessexahsn.net