Learning from Death’s Policy€¦ · Web viewLearning from such reviews will be communicated via a range of channels including the Learning from Deaths Report and the Lessons

DCHS Learning from Deaths Policy

Learning from Death’s Policy Document History

Modified Date: 20/03/2018

Version Number: 3 Reference Number: P72

Next Revision Due: Annually[Review Period]20/03/2019

Review Status Approved

[Review Status]Author: Owolabi Bola (RY8) Derbyshire Community Health Services

Policy Sponsor: Meredith Rick (RY8) Derbyshire Community Health Services

Team: Clinical

[Published Team]Approved by: Quality Service Committee [Committee Approving or Rejecting]Date: 20/03/2018

Category: Clinical

[Service Category]Sub Section: Clinical Services[Title / Sub-Category]Type of Document: Policies

[Document Type]Have you assessed the Equality Impact of this policy?

(please see section 12)

Contact Name for Policy Queries Owolabi Bola (RY8) Derbyshire Community Health ServicesContact Name for SharePoint document upload [email protected]

Key Words mortality, end of life, case note review, duty of candour, investigation

Comments

Board Responsibility discharged through detailed examination of the Learning from deaths report at the Quality Services Committee meetings under the oversight of the Corporate Leads:Dr Rick Meredith – Executive Medical DirectorProfessor Chris Bentley - Lead Non-Executive Director for Mortality Reviews as per National Guidance

Please indicate which groups have discussed this policy: QualityDate(s) discussed: 03/07/2017Mortality Review Group 22/02/2018

Has this Policy previously been known under another title? If so, please state previous title.

Mortality Review Policy

Date changed: December 2017

Revision HistoryVersion Revision date Summary of Changes1 June 2017 Development of new policy2 November 2017 Title Changed to Learning from Deaths Policy3 February 2018 Comments section of Table of Content updated to reflect Board

responsibilities more clearly.To help ensure that this policy is as accessible as possible, it has been left-aligned and is available in alternative formats and languages. To obtain a copy of the policy in large print, audio, Braille (or

Version 2 Page 1 of 21 Review Date

mailto:[email protected]


other format) or in a different language, please contact The Communications Team, by Tel: 01246 515224 or email [email protected]

TABLE OF CONTENTS

1 Aim/Purpose....................................................................................................................................3

2 Intended Users................................................................................................................................4

3 Disclaimer Statement......................................................................................................................4

4 Definitions and An Explanation of Terms Used...........................................................................5

5 Full Details of The Policy................................................................................................................65.1 Reporting and Initial Review of Deaths......................................................................................6

5.2 Central Recording of Deaths......................................................................................................65.3 Initial Death Review....................................................................................................................7

5.3.1 Initial Death Review Outcome Criteria Investigation Requirements....................................75.4 Responding to Deaths................................................................................................................8

5.4.1 Multi Agency Response.......................................................................................................85.4.2 Specified Categories of Deaths...........................................................................................95.4.3 Referred Deaths..................................................................................................................95.4.4 Expected Deaths.................................................................................................................9

5.5 Support and Engagement with The Bereaved..........................................................................105.5.1 Signposting and Guidance................................................................................................10

5.6 Case Note Review....................................................................................................................105.6.1 Investigation and Case Note Review Timescales.............................................................10

5.7 Consent....................................................................................................................................115.8 Minimum Standards For Mortality Review Process..................................................................11

6 Education and Training................................................................................................................11

7 Support and Additional Contacts................................................................................................12

8 Supporting Documents or Relevant References.......................................................................12

9 Consultation and Approval..........................................................................................................13

10 Monitoring/Audit........................................................................................................................1310.1 Monitoring Compliance with The Document.........................................................................13

11 Governance................................................................................................................................14

12 Equality Impact...........................................................................................................................1412.1 Equality Analysis Summary..................................................................................................14

13 Dissemination And Implementation.........................................................................................15

14 Appendices.................................................................................................................................1514.1 Appendix 1 – Monitoring/Audit Tool......................................................................................16

14.2 Appendix 2 - Flow Chart for the Mortality Review Process...................................................1614.3 Appendix 3 - “In Depth Review” Mortality Summary Sheet..................................................17

14.4 Appendix 4 – Duty of Candour..............................................................................................2114.5 Appendix 5 – Mortality Review Group Terms of Reference..................................................21




14.6 Appendix 6 – End of Life Strategy........................................................................................21

14.7 Appendix 7 – Investigation of Incidents, Complaints and Claims.........................................21

1 Aim/Purpose

This policy confirms the process to ensure a multi-disciplinary, consistent and coordinated approach for the review of deaths that occur in all DCHS in-patient and community team caseloads.

The aim of the learning from deaths process is to identify any areas of practice both specific to the individual case and beyond that could potentially be improved, based upon peer group review. Areas of good practice are also identified and supported.

To describe in detail the three-stage mortality review process within the Trust, detailing how reviews should be completed, by whom and when to ensure that learning from deaths is made a Trust priority and leads to developments and improvements in patient care.

The purpose of these reviews is to highlight lapses in care that may have contributed to a death and to learn from the death to prevent, where possible, recurrence. The outputs from mortality reviews are; shared learning and corrective actions undertaken.

The learning from death process will ensure that there are clear auditable reporting mechanisms in place, to escalate any areas of concern identified: to the clinicians concerned; and the appropriate Committees through to DCHS Trust Board so that they are aware and can take appropriate action.

This policy outlines how DCHS responds to, and learns from, deaths of patients who die under its management and care, whether or not they meet the definition of a serious incident (SI) in accordance with the National Quality Board’s National Guidance on Reporting and Learning from Deaths.

The Learning from death policy does not replace existing policies relating to the review of deaths e.g. LeDER. However, it provides an overview of the current processes, policies and approaches to reviewing death in DCHS.

The policy also clarifies:

approach in undertaking case record reviews

Categories and selection of deaths in scope for case record review

Categories and selection of deaths out of scope for case record review and our rationale for exclusion.

DCHS’ approach to meaningful involvement and engagement of bereaved families and carers in the investigation of deaths deemed as more likely than not to be avoidable following case note review.

Our data collection and reporting approach: The data will include How our processes respond to the death of an individual with a learning disability, or mental health needs, an infant or child death and a stillbirth or maternal death

The Trust’s



a) The total number of deaths (In-patients (including OPMH) & Community Team caseloads)

b) Deaths subjected to case record review. c) Deaths deemed avoidable following case note review

Quality Account: The data published by DCHS in our Public Board papers will be summarised in the Quality Account from June 2018 including evidence of learning and action as a result of this information and an assessment of the impact of actions taken by the Trust.

Our Guiding Principles: Improved speed of response to concerns. An open and transparent learning culture. Continuous quality improvement through lessons gained from the mortality review

process.

NHS staff work tirelessly under increasing pressures to deliver safe, high-quality healthcare. When mistakes happen, Providers working with their partners need to do more to understand the causes. The purpose of reviews and investigations of deaths, which lapses in care might have contributed to, is to learn in order to prevent recurrence. Reviews and investigations are only useful for learning purposes if their findings are shared and acted upon. DCHS intend to share learning both within and outside our organisation to facilitate wider improvements across the health and social care system. This will be achieved by sharing learning and recommendations from mortality reviews with the team to whom the case reviewed relates, Lessons Learned Panel and by secure email communication with organisations external to DCHS where this is relevant and appropriate.

2 Intended Users

DCHSChief Executive’s Department YES

Finance Performance and Information YESQuality YES

Strategy YESOperations YES

People & Organisational Effectiveness YESGeneral Practices (GP) YES

Where this policy where states “all employees”, please note that it relates to all the employees who are highlighted in the table above

3 Disclaimer StatementIt is a requirement that the reader follows this policy and accepts professional accountability and maintains the standards of professional practice as set by the appropriate regulatory body applicable to their professional role and to act in accordance with the express and implied terms of your contract of employment, in accordance with the legal duties outlined in the NHS Staff Constitution (section 3b). If there are any concerns with this document, then the reader should initially discuss the specific issue with their line manager or raise it through appropriate



“raising concerns” channels. The line manager should agree a course of action that is appropriate and reflect this in the patients notes and with the policy sponsor.

4 Definitions and an Explanation of Terms UsedTerms ExplanationAvoidable/Preventable

Something that is avoidable can be prevented from happening. These terms are used interchangeably in the NHS and for the purpose of this policy ‘avoidable’ or ‘unavoidable’ will be used with reference to whether anything could have been done to change the outcome.

Case Record Review

Is a process aimed at obtaining retrospective information to determine if care was delivered within expected standards. The application of a case record/note review to determine whether there were any problems in the care provided to the patient who died in order to learn from what happened.

Complication An additional problem that arises following a procedure, treatment or illness and is secondary to it/complicates the situation.

Death due to a problem in care

Death due to a problem in care : A death that has been clinically assessed using a recognised method of case record review, where the reviewers feel that the death is more likely than not to have resulted from problems in caredelivery/service provision. (Note, this is not a legal term and is not the same as ‘cause of death’). In DCHS such deaths would be given a Death Classification of 1.

Investigation The act or process of investigating; a systematic analysis of what happened, how it happened and why. This draws on evidence, including physical evidence, witness accounts, policies, procedures, guidance, good practice and observation - in order to identify the problems in care or service delivery that preceded an incident to understand how and why it occurred. The process aims to identify what may need to change in service provision in order to reduce the risk of future occurrence of similar events.

Mortality For the purpose of the Learning from deaths Learning from deaths Report, mortality relates to:i) All deaths classified as avoidable by the Mortality Review Group

following case note review and using the avoidability of death scale (See Table 1)

ii) Cases where concerns have been raised in relation to the care of deceased patients – these are expected to be identified by incident reporting

iii) All cases subject to Serious Incidents investigations(SI))/Cases reported to the Coroner

iv) Deaths where complaints, concerns or incidents have been reported in relation to the end of life care provided to the deceased requiring further case review

v) Deaths of patients with known mental health diagnosis (In-Patients Only)vi) Deaths of patients with learning disabilityvii) Infant deaths, still births, maternal deathsviii) A proportion of deaths that are classified as expected and for which no

concerns were raised (3 every 6 months)Mortality Review Group (MRG)

A multi-disciplinary group that reviews and discusses clinical cases, outcome data (clinician and patient reported) and related information (e.g. SI, complaints, other benchmarking data).

Policy A statement of the Board’s agreed position and governing principles in relation to particular issues or situations. In the context of this policy the



subject is relating to Mortality Review Process.Lead Non-Executive Director for Learning from deaths

The Trust nominated Lead Non-Executive Director for Mortality oversees the Trust’s approach to learning from patient deaths and guidance on this role can be found within Appendix B of the National Guidance on Learning from Deaths produced by the National Quality Board. The role of the nominated Non-Executive Director for learning from deaths is to ensure that there are mortality review processes in place that are ‘robust, focus on learning and can withstand external scrutiny, by providing challenge and support’ with quality improvement as the purpose of the exercise’.

NRLS The National Reporting and Learning System (NRLS) is the central database of all patient safety incident reports. The Trust regularly submits data to this national database which is analysed nationally to identify hazards, risks and opportunities to continuously improve the safety of patient care on a national basis. Reports are produced every six months by NHS Improvement. The NRLS also shares information on incidents to the Care Quality Commission.

Regulation 28 The Coroner has a legal power and duty to write a report following an inquest if it appears there is a risk of other deaths occurring in similar circumstances. This is known as a 'report under regulation 28' or a Preventing Future Deaths Report (PFD) because the power comes from regulation 28 of the Coroners (Inquests) Regulations 2013. The Executive Medical Director is responsible for liaison with the Coroner and the Trust must reply within 56 days to say what action we plan to take or have taken already.

STEIS The Strategic Executive Information System is an electronic database through which the Providers communicate serious incidents to the Commissioners. This detail is accessible by the CQC and helps to inform Provider inspections. The Patient Safety team are responsible for recording serious incidents onto STEIS.

Serious Incident (SI)

An accident occurring on NHS premises that resulted in serious injury, and or permanent harm, unexpected or avoidable death (ref SI details).

Never Event Never Event Incidents are serious, preventable patient safety incidents that should not occur if the available preventative measures have been implemented by the healthcare provider. These are reviewed on an annual basis and are available on the Department of Health website. https://www.england.nhs.uk/patientsafety/never-events/

Quality Improvement

A systematic approach to achieving better patient outcomes and system performance by using defined change methodologies and strategies to alter provider behaviour, systems, processes and/or structures.

5 Full Details of the Policy5.1 Reporting and Initial Review of DeathsCompliance with this section of the policy will ensure the Trust follows the National Quality Board’s Guidance on Learning from Deaths.

5.2 Central Recording of DeathsThere are existing mechanisms for recording deaths in DCHS. As part of implementing the learning from deaths policy, these are being developed further through the creation of a central Learning from Deaths reporting system whereby data on deaths are drawn from the Electronic Patient Records (EPR). These will be cross-referenced with other review processes e.g. deaths subject to coroner’s inquest, safeguarding reviews, etc. The cross-referenced data will be held on the Quality Drive pending further development of a bespoke mortality IT platform.


https://www.england.nhs.uk/patientsafety/never-events/


5.3 Initial Death ReviewThe mortality review facilitator will work with appropriate clinical lead for ensuring the completion of the Initial Death Review within three working days of the Trust becoming aware of a death. The data will be pulled from the Quality Drive as described above. The initial death review should:

Identify and provide assurance that any necessary immediate action to ensure the safety of patients, staff, and the public is in place

Assess the death according to the criteria below and determine whether Outcome 1, 2 or 3 apply and propose the level of investigation or case note review required

Provide details of communication with the family and any information regarding the application of the Duty of Candour

The Initial Death Review Report should be uploaded to the Quality Drive.

This review also acts as a triage to determine whether the death should be reported on STEIS as a serious incident and the level of investigation required. The outcome of the Initial Death Review will be either:

Outcome 1 - With the facts known it meets the definition of an SI – if not already recorded, this would require reporting on Datix & STEIS.

Or

Outcome 2 - The death does not appear to meet the definition of an SI but does need to be looked at in more detail and a case note review is warranted.

Or

Outcome 3 - There are no apparent issues that need to be explored.

NB: If following the Initial Death Review in 3 working days, any of the Outcome 1 or 2 criteria are found to have been met, the process will start from that date.

Recording the outcome of decision whether or not to review or investigate a death: Following initial death review (IDR) as detailed above, if the outcome is Outcome 3, the rationale for this decision will be recorded and updated on the Quality Drive.

5.3.1 Initial Death Review Outcome Criteria Investigation Requirements

Outcome 1 - The definition of an SI is met (see Section 4), as a minimum this relates to the following deaths:

Apparent suicide/ self-inflicted death/ accidental overdose

Apparent homicide – perpetrator or victim – These will normally be received via safeguarding processes

Deaths where abuse or neglect is known - These will normally be received via safeguarding processes



Deaths following a Never Event

Deaths of patients detained under the MHA/CTO or subject to recall

Deprivation of Liberty applied (including care home)

The Initial Death Review will propose a comprehensive investigation is conducted as per NHS England SI Framework or a case note review and provide rationale for this.

Outcome 2 – The definition of an SI has not been met, however the following apply: All deaths where bereaved families and carers, or staff, have raised a significant

concern about the quality of care provision;

All deaths in a service specialty, particular diagnosis or treatment group where an ‘alarm’ has been raised with DCHS through whatever means (for example raised by audit work, concerns raised by the CQC or another regulator);

All deaths in areas where people are not expected to die, for example death occurring within 30 days of day case surgery/elective procedure

Deaths where learning will inform DCHS’ existing or planned improvement work, for example if a death is reported via DCHS End of Life Care audit as being due to sepsis, such a death will be reviewed.

All unexpected in-patient deaths (including OPMH)

Deaths within the Integrated Community Services (ICS) division where complaints/ concerns/incidents have been reported in relation to the patient’s end of life care.

All deaths subjected to Coroner’s inquest (and the death has not already been investigated or reviewed by the Trust)

A proportion of expected deaths e.g. of patients receiving end of life care

Cases flagged through the Trust’s Bereavement Survey

If the above apply, a Case Notes Review should be conducted.

Outcome 3 – The criteria for Outcome 1 and 2 have not been met, therefore no further investigation is required. Rationale for this will be provided. In these cases, the final stage will be updating the Quality Drive. However, Case Notes Review will be conducted in a sample of “no-concern” deaths. Five “no-concern” deaths will be reviewed by the Mortality Review Group on a six-monthly basis.

The template for Initial Management and Death Review Reports are available in the Quality Drive. All Initial Death Review Reports which meet outcome 1 will be reviewed via the process outlined in the existing Serious Incident/Issues Review policy. Outcomes from the Serious Incident Investigation will be included in the Learning from deaths report to Quality Service Committee (QSC). Additionally, all case note review findings for deaths which meet Outcome 2 criteria will also be included in the Learning from deaths Report.

5.4 Responding to Deaths 5.4.1 Multi Agency ResponseReporting death within DCHS and to other organisations that may have an interest (including the deceased person’s GP). The mortality review process is shown in Appendix 2 (Flow Chart). On receipt and review of the Case Note Reviewer(s) reports, the MRG will assess the avoidability of the death. Where a death is deemed to have been more than likely to be avoidable, the MRG will escalate this to the Service General Manager for further investigation.



The General Manager is required to instigate Duty of Candour processes to undertake a root cause analysis investigation and to determine learning. Other organisations that may have interest (including the patient’s GP) will be notified as part of the investigation process. The MRG will also report all deaths subjected to case note review to the QSC.

5.4.2 Specified Categories of DeathsResponding to the death of an individual with a learning disability, or mental health needs, an infant or child death and a stillbirth or maternal death. The following categories of deaths (except severe mental illness) are excluded from our case note review process because they are reviewed via independent processes to DCHS. However, learning from these deaths will be captured and communicated across DCHS through various governance groups in the Trust including Mortality Review Group, Clinical Safety Group, Lessons Learned Panel, Safeguarding Governance Group and external organisations such as Derby Safeguarding Children Board sub-group, the Serious Case Review Group, the Derbyshire Safeguarding Adults Board, Domestic Homicide Review Group and Fatal Fire Review Panel.

The death of an individual with a learning disability will be reviewed via the regional LeDER programme

Deaths of patients within the OPMH service (severe mental health needs) will be subjected to case note review through the DCHS mortality review process. The case note review report will be discussed by the Mortality Review Group with a view to identifying any lapses in care and learning from these. The findings will be communicated via the communication links of the MRG and the Learning from deaths Report to QSC

Infant or child death are reviewed via the Derbyshire Safeguarding Children Board Child Death Overview Panel

Stillbirth or maternal deaths are reviewed via the Confidential Enquiries into Maternal and Infant Deaths.

5.4.3 Referred DeathsReviewing the care provided to patients not under the care of DCHS at the time of death but where another organisation suggests that the Trust should review the care provided to the patient in the past; In instances where DCHS is notified by Partner organisations of the need to review the care provided to patients not under the Trust’s care at the time of death, the Trust will respond in a timely manner. Review of the death will be carried out through the Mortality Review Process outlined in Appendix 2 Flow Chart. There may be instances where it is more appropriate for the review to be carried out by other groups within the Trust. Learning from such reviews will be communicated via a range of channels including the Learning from Deaths Report and the Lessons Learned Panel.

5.4.4 Expected DeathsReviewing the care provided to patients whose death may have been expected, for example those receiving end of life care; DCHS has an established end of life care audit programme. This is the mechanism by which the Trust reviews the care provided to patients whose death may be expected for example end of life care. The end of life audit programme assesses the quality of care delivered against the standards within the One Chance to Get It Right document in line with the Five Priorities of Care.

5.5 Support and Engagement with the Bereaved



Engaging meaningfully and compassionately with bereaved families and carers is a key priority for DCHS. The existing DCHS Complaints and Concerns Policy is geared towards meaningful and compassionate involvement with bereaved families and carers. Contact is coordinated by the Patient Experience Team. All bereaved families and carers are offered a meeting at the outset as this often strengthens their confidence in the process. The Patient Experience Team will provide support within the complaints processes to ensure concerns are investigated and responded to in a timely manner. Bereaved families and carers are offered a meeting at the end of the complaint investigation process to share the findings.

5.5.1 Signposting and GuidanceEveryone who has concerns investigated under the complaints procedure, including bereaved families and carers are advised on what to do should they remain dissatisfied with the outcome of the complaint investigation and response to their concerns. Information on how to contact the Parliamentary and Health Service Ombudsman (PHSO) is provided in every complaint response letter. The PHSO will review the complaint and the way in which it has been handled by the Trust. The Complaints and Concerns Policy provides further information and guidance on complaints handling within the organisation.

5.6 Case Note Review Case note reviews will be completed for deaths that do not meet the definition of an SI but would benefit from a further review. This will be implemented through a phased approach prioritising in-patients, where bereaved families or staff have raised concerns. Until this is fully rolled out, a Level 1 concise investigation will be always be conducted for these deaths to ensure they are subject to a review.

Individual case note reviewers will apply the following tools for conducting the case note review objectively:

There is currently no consensus on the best case note review tool to use in Community and Mental Health settings. DCHS will adapt existing tools and methodologies including:

Global Trigger Tool (Community element)Structured Judgment Review (SJR) methodologyPRISM methodologySuicide Review ToolExisting modified DCHS RCA Tool

This will mean that at this point in the Learning from death process our case note review tool will be a hybrid of the above (This process is currently being developed)The case note reviewer will employ whichever tool is most suitable and appropriate to the case under review

5.6.1 Investigation and Case Note Review Timescales Investigations into STEIS reported serious incidents are required by commissioners to be completed within 60 working days. In exceptional circumstances an extension to this time frame can be applied for to the Commissioners by the Divisions on request from Division Governance Teams.

Internal SIs and case note reviews should also be completed with 60 working days.

There may be occasions where an internal investigation cannot start until an external agency has given the go-ahead i.e. Police, Coroner, Fire Service, Health and Safety Executive, etc. In



such cases it may also be possible to coordinate or combine the investigation with the external body.

The Mortality Review Facilitator will be responsible for monitoring and ensuring that required timescales are being met and escalating via appropriate mechanisms where there may be potential breaches. They will also ensure that case note reviews are carried out accordingly and in a timely manner using objective case note review tools and techniques.

5.7 ConsentThe Consent Policy must be adhered to. In the case of deceased patients this must be raised with the Responsible Clinician with reference to the Mental Capacity Act Policy and Procedure

5.8 Minimum Standards for Mortality Review Process For meetings to take place regularly and all associated processes to be completed in line

with DCHS Trust policies. To provide Learning from deaths Report to QSC for onward publication in Public Board

papers to include o total number of deathso deaths reviewed by Mortality Review Groupo deaths deemed avoidable by Mortality Review Groupo Log of deaths subject to investigation/review processes by external bodies e.g.

Coroners or other groups within DCHS e.g. as part of SUIs process..o deaths flagged to DCHS for review by partner organisations (Health and Social Care)o learning from deaths subjected to case note reviewo learning from other mortality review processes – Learning Disabilities Mortality Review

(LeDER) Programme, Child Death Overview Panel, The Confidential Enquiry into Maternal Deaths (CEMD)

6 Education and Training Training is a key element to the successful implementation of this policy. There is currently no nationally defined training programme for case note reviewers in Community Trusts. Pending the availability of this, DCHS Case Note Reviewers and members of the MRG will receive formal RCA training. This will be mandatory and conducted at 3 yearly intervals. A learning pathway will be created on ESR for members of staff involved in this process in order to ensure robust training compliance monitoring. Once a national case note review training programme is available for Community Providers, DCHS case note reviewers will engage and comply fully with the training requirements.

Staff TrainingTraining regarding the incident reporting and investigation procedures will be delivered in various forms for all staff and will be covered in:

Staff Induction (local)

Training Needs Analysis

Essential Skills and Training

Guidance (to be made available on myDCHS)



Training for undertaking case note reviews will be developed. The Case Note Reviewers require training on the use of the various case note review tools/methodologies. Members of the MRG require formal RCA training and updates at regular intervals.

In the Community Hospitals, Outpatients and Community based teams, all staff who provide patient care should have an awareness of this policy. This will better aid their understanding of the policy aims in demonstrating effective and safe patient care and provide a clear vision on the importance of their role in this process.

Where managers identify the need for some specific training in this policy and procedure they should contact the Training & Workforce Development Team.

7 Support and Additional ContactsThe individuals responsible for developing the document and from whom additional support and advice can be obtained in order to implement the document.

Deputy Medical Director [email protected] Tel: 07886 499135

Clinical Lead for Advanced Practice [email protected] Tel: 07765 863054

Head of Patient Safety & Risk Management [email protected] Tel: 07824 624452

Head of Patient & Family Centred Care [email protected] Tel:07979653837

Mortality Review Facilitator [email protected] Tel: 07867466104

Quality Triage Office 01246515870

8 Supporting Documents or Relevant References National Guidance on Learning from Deaths: A Framework for NHS Trusts and NHS

Foundation Trusts on Identifying, Reporting, Investigating and Learning from Deaths in Care’ and the earlier CQC Learning, Candour and Accountability report.

The Learning Disability Mortality Review Programme (LeDER) http://www.hqip.org.uk/national-programmes/a-z-of-clinical-outcome-review-programmes/learning-disability-mortality-review-programme/

Transforming Care for People with Learning Disability- Next Steps https://www.england.nhs.uk/learningdisabilities/care/

LeDER Process Flowchart Confidential Inquiry into premature deaths of people with learning disabilities (CIPOLD)

http://www.bristol.ac.uk/cipold/ Learning, candour and accountability - A review of the way NHS trusts review and

investigate the deaths of patients in England https://www.cqc.org.uk/sites/default/files/20161213-learning-candour-accountability-full-report.pdf

Learning from deaths in the NHS https://improvement.nhs.uk/resources/learning-deaths-nhs/

The Mid Staffordshire NHS Foundation Trust Inquiry; Independent Inquiry into care provided by Mid Staffordshire NHS Foundation Trust; January 2005 to March 2009;








Volume 1. Chaired by Robert Francis QC, Published 24 February 2010. https://www.gov.uk/government/publications/independent-inquiry-into-care-provided-by-mid-staffordshire-nhs-foundation-trust-january-2001-to-march-2009

DCHS’ Incident & Serious Incident (SI) Policy DCHS’ Bereavement Survey Using the structured judgement review method A guide for reviewers

9 Consultation and Approval Consultation The Deputy Medical Director has delegated responsibility for the review of the Learning

from Deaths Policy. The document has been written with advice from Medical Directorate Clinicians and Mortality Review Group members.

This policy has been developed based on requirements outlined in the ‘National Guidance on Learning from Deaths - A Framework for NHS Trusts and NHS Foundation Trusts on Identifying, Reporting, Investigating and Learning from Deaths in Care’.

The draft policy has been circulated to the Quality Services Committee (Deep Dive session), Clinical Lead for Advanced Practice, Head of Patient Safety & Risk Management, Safe Care Officer, Deputy Chief Nurse, Clinical Effectiveness Facilitator and the Patient Safety Team for comments and amendments made where necessary.

An equality impact assessment has been conducted on this policy to ensure its consideration to the impact on local vulnerable people and those from the protected equality groups.

Trust Board The Trust Board is responsible for setting the strategic context in which the organisational procedural documents are developed. The Board will approve strategies for implementation. Depending upon the nature of the procedural document, the Board may also be asked to ratify procedural documents making them valid by formally confirming approval.

Committees The Deputy Medical Director will present a final copy of the policy to the Mortality Review Group (MRG) for comment and QSC for approval.

10 Monitoring/Audit It is necessary to routinely check whether or not a policy is being followed. Appendix 1 should be completed for all clinical policies and can be used to determine compliance for all policies. This section should also be used to make reference to any other monitoring of this policy (e.g. planned audits).

10.1 Monitoring Compliance with the Document This policy will be monitored and reviewed by the MRG, for key indications.

The data collected from the monitoring process will be available for inspection by the NHS Litigation Authority and other appropriate external bodies. The outcome of the monitoring will be reported to the MRG and QSC.


http://IMPROVEMENTACADEMY.ORG/DOCUMENTS/PROJECTS/AVOIDABLE_MORTALITY/NMCRR%20GUIDE%20ENGLAND.PDF


11 Governance Key Performance Indicators

The MRG will hold bi-monthly meetings and have agreed Terms of Reference. A quarterly assurance report including any data regarding number of deaths and

classification assigned to them, and the summary of the meetings, will be provided to QSC.

The Deputy Medical Director, Chair of the Mortality Review Group will provide an Annual Report to QSC.

Information Governance The minutes of the MRG will summarise the discussion taking place at the meeting,

including outcomes of individual reviews. The reports concerning individual cases and discussion relation to them are confidential

and shall be exempt from requests under the Freedom of Information Act.

Duty of Candour and Raising Concerns Where issues or incidents not previously identified or raised are found during a review of the patient care the MRG will report the incident according to the usual Trust process.

12 Equality Impact

12.1 Equality Analysis SummaryAll public bodies have a statutory duty under The Equality Act 2010 (Statutory Duties) Regulations 2011 to provide, “evidence of the analysis it undertook to establish whether its policies and practices would further, or had furthered, the aims set out in section 149(1) of the [Equality Act 2010]”, in effect to undertake a written record of equality analysis and due regard on all procedural documents and practices.


What effect or impact will the new/changed policy have on each of the Protected Characteristics (age, gender, disability, gender reassignment, marriage or civil partnership, pregnancy or maternity, race, religion or belief, sexual orientation)?

This policy will ensure that equal focus is given to the review of deaths of patients with learning disability, maternity deaths, patients with mental health diagnosis and patients with other/no protected characteristics

If this effect or impact is negative or disadvantages one or more of the Protected Characteristics, what changes are going to be made to either remove entirely or minimise this effect or impact? (Note: if the policy could be discriminatory, seek immediate advice from the Head of Equality, Diversity and Inclusion)

N/A


Derbyshire Community Health Services, NHS FT considers how the decision it makes affects people who share different protected characteristics (race, disability, sex, gender re-assignment, religion/belief, sexual orientation and age). DCHS also recognises that there are groups/communities that are recognised at a local level within society as excluded or disadvantaged in addition to those listed as protected groups above and this document is inclusive to these groups also for example, young teenage parents, homeless people etc.

The policy applies to all groups and there will be no discrimination based on age, race, disability, sex, gender re-assignment, religion/belief or sexual orientation. Where discrimination is noted this will be addressed through the Human Resources Framework and may result in disciplinary actions. A completed Equality Analysis is presented at appendices 2a and 2b of this document.

13 Dissemination and Implementation

Dissemination The document will be published electronically on the DCHS Trust intranet.

ImplementationThis policy has some significant changes to previous policy, particularly the introduction of Initial Death/Management Reviews, Case Note Reviews and the central recording and monitoring of deaths. Full implementation of this policy will not be immediate and therefore implementation will be incremental and subject to evaluation.

The policy will be announced to all relevant staff via the communications e-bulletin (Safe Care Newsletter) with the support of the Patient Safety and Communication Teams

The policy will be disseminated via leadership and teams briefings and the MRG.

The Mortality Administrator will be a key role in ensuring the successful implementation of this policy. They will co-ordinate the processes covered by this policy and will ensure that all those involved in the process are aware of their responsibilities and the requirements of the policy.

14 Appendices

Appendix 1 – Monitoring & Audit ToolAppendix 2 – Flow Chart for the Mortality Review ProcessAppendix 3 – “In Depth Review” Mortality Summary SheetAppendix 4 – Being Open and Duty of CandourAppendix 5 – Terms of Reference for Mortality Review GroupAppendix 6 – End of Life StrategyAppendix 7 – Investigation of Incidents, Complaints and Claims



14.1 Appendix 1 – Monitoring/Audit Tool

CORE STANDARDS (relevant to this policy)

Indic. No

Description of the Core Standard Standard (%)

Exception’s Definitions and Instructions

1 Mortality Review Group to meet bimonthly 100%

2 Mortality Review Group to provide Quarterly Report to QSC 100%

3 Quarterly Learning from deaths Report to be published in public Board papers 100%

4 In-depth Case Note Review Report to be presented to MRG bi-monthly by the Case Note Reviewer 100%

5 In-depth Case Note Review of all eligible categories to be conducted monthly by the Case Note Reviewer 100%

6 Five no concern deaths to be reviewed every 6 months 100%

14.2 Appendix 2 - Flow Chart for the Mortality Review Process


http://share.derbyshirechs.nhs.uk/sites/DCHS-Policies/HyperLDocs/Flow%20Chart%20for%20the%20Mortality%20Review%20Process.docx


14.3 Appendix 3 - “In Depth Review” Mortality Summary Sheet

Learning from Deaths Investigation Report: Insert Unique IDFIRST STAGE REVIEWDetails of Death

Brief description:

Date of Death:NHS No:

Specialty:Relevant PMH:

Cause of Death:

Level and Scope of Investigation

Involvement and Support of Relatives

Chronology (timeline) of EventsDate & Time Event

Detection of Incident

What were the Triggers for this review (please tick all that apply)

Serious Incidents relating to the care of deceased patientCase subject to an inquest / Cases reported to the CoronerMortality or End of Life related ComplaintMental Health DeathEnd of Life / Mortality AuditDeath in which Duty of Candour process was in place (where the subject matter is related to the patient’s death



Areas of Good Practice

Care and Service Delivery Problems

Contributory Factors

Overall Quality Of CareScore 1 Unsatisfactory: care fell short of current best practice in one or more significant areas resulting in the potential for, or actual, adverse impact on the patientScore 2 Care fell short of current best practice in more than one significant area, but is not considered to have the potential for adverse impact on the patientScore 3 Care fell short of current best practice in only one significant area, but is not considered to have the potential for adverse impact on the patientScore 4 This was satisfactory care, only falling short of current best practice in more than two minor areasScore 5 This was good care, which only fell short of current best practice in one or two minor areasScore 6 Very best care: this was excellent care and met current best practiceQuality of RecordsA Medical records were adequate to make a reasonable judgementB Some deficiencies in the records (specify)C Major deficiencies (specify)D Severe deficiencies, impossible to make judgements about problems in care

Reviewer and Job Title



SECOND STAGE REVIEWRoot Causes

The death is thought to be more likely than not due to a problem in careYes / No (Delete as appropriate)

Complete specific areas of problems in care below

Problem in assessment, investigation or diagnosisAdd text here

Problem with medication, IV fluids, Electrolytes, oxygenAdd text here

Problem related to treatment and management planAdd text here

Problem related to operation/ invasive procedureAdd text here

Problem in clinical monitoringAdd text here

Problem with infection managementAdd text here

Problem of any other type not fitting the categories aboveAdd text here

Death Classification – Locally agreed 5 point scale applied to cases subject to a case note reviewProblems in care thought more likely than not to have contributed todeath 1

Problems in care but unlikely to have contributed to death 2Problems in care but very unlikely to have contributed to death 3No problems in care 4Good or Excellent Care. 5

Lessons LearnedAdd text here

RecommendationsAdd text here

Arrangements for Shared LearningAdd text here



Date of Mortality Review GroupAdd date here

Actions Taken(identify person responsible for action and date action to be completed (SMART))

Action required Action by date Person responsible Action Status



14.4 Appendix 4 – Duty of CandourBeing Open and Duty of Candour

14.5 Appendix 5 – Mortality Review Group Terms of Reference

14.6 Appendix 6 – End of Life Strategy

14.7 Appendix 7 – Investigation of Incidents, Complaints and ClaimsComplaints and Concerns Policy (to be updated once revised policy is available)


http://share.derbyshirechs.nhs.uk/sites/DCHS-Policies/PoliciesProcedures/Forms/Upload1.aspx