Learning from Deaths (Mortality Review) Policy

Transcription

1 Learning frm Deaths (Mrtality Review) Plicy Apprval Cmmittee Versin Issue Date Review Date Dcument Authr TMB 4 Dec 17 Dec 19 Dr Tiwari, Dr Cranshaw, Janne Sims CONSULTATION PROCESS Versin Date Authr Level f Cnsultatin 1 2 June 13 Sept 14 LIPS Team HAC, PMG, TMB, Mrtality Grup and Bard f Directrs Mrtality Grup, MICE Grup 3 Jan 16 DT/JS Mrtality Grup, TMB, QARC 4 Dec 17 DT/JS Mrtality Grup, TMB, QARC V4 Oct 17 1

2 Learning frm Deaths (Mrtality Review) Plicy 1.0 Intrductin 1.1 It has becme increasingly imprtant fr Trusts t prvide evidence that they are systematically and cntinuusly reviewing patient utcmes and especially mrtality and mrbidity. Learning frm deaths that ccur within the hspital is an imprtant part f the Trust bjective prviding the excellent care we wuld expect fr ur families. Reviewing the care prvided t peple wh have died can help imprve care fr all patients by identifying prblems assciated with pr utcmes, and wrking t understand hw and why these ccur s that imprvement actin can be taken. The bard is cmmitted t prviding visible and effective leadership t ensure the rganisatin addresses any significant issues identified in reviews and investigatins. 1.2 Under the Natinal Guidance n Learning frm Deaths, published by the Natinal Quality Bard in March 2017, trusts are required t have a learning frm deaths plicy that shuld meet the fllwing bjectives: the prcesses respnd t the death f an individual with a learning disability, severe mental illness, an infant r child death, a stillbirth r a maternal death there is an evidence-based apprach t undertaking case recrd reviews the trust engages with bereaved families and carers staff affected by the deaths f patients are supprted. The Natinal guidance als requires this t be a transparent prcess where the Bard f Directrs receive a quarterly reprt (in the public sectin f the meeting) n: the ttal number f inpatient deaths the number f deaths subjected t frmal case recrd review the number f deaths investigated under the Serius Incident framewrk (and declared as Serius Incidents) the themes and issues identified frm review and investigatin, including examples f gd practice hw the findings frm reviews and investigatins have been used t infrm and supprt quality imprvement activity and any ther actins taken, and prgress in implementatin. This plicy sets ut the Ryal Burnemuth and Christchurch Hspitals NHS Fundatin Trust apprach t meeting these requirements. 2.0 Plicy Scpe 2.1 This plicy applies t all staff whether they are emplyed by the trust permanently, temprarily, thrugh an agency r bank arrangement, are students n placement, are party t jint wrking arrangements r are cntractrs delivering services n the trust s behalf. V4 Oct 17 2

3 3.0 Purpse The Ryal Burnemuth and Christchurch Hspitals NHS Fundatin Trust will implement the requirements utlined in the Learning frm Deaths framewrk as part f the rganisatin s existing prcedures t learn and cntinually imprve the quality f care prvided t all patients. This plicy sets ut the prcedures fr identifying, recrding, reviewing and investigating the deaths f all inpatient in the care f the Trust. This plicy describes hw the Trust will supprt peple wh have been bereaved by a death at the trust, and als hw thse peple shuld expect t be infrmed abut and invlved in any further actin taken t review and/r investigate the death. It als describes hw the trust supprts staff wh may be affected by the death f smene in the trust s care. It sets ut hw the trust will seek t learn frm the care prvided t patients wh die, as part f its wrk t cntinually imprve the quality f care it prvides t all its patients.. This plicy shuld be read with reference t the Trust Learning Event Reprt Ntificatin (LERN) Plicy, RCA and SI Tlkit and Duty f Candur guidance. 4.0 Definitins 4.1 Mrtality Fr the purpse f this plicy, mrtality relates t any in-hspital deaths. 4.2 Mrtality Reviews structured retrspective case recrd review A systematic exercise t review case recrds retrspectively using a structured methdlgy. The prcess is used t identify any deficiencies and/r excellence in clinical care and cmmunicatin. The review is used t draw learning r cnclusins t infrm any further actin that is needed t imprve care acrss the Trust. 4.3 Care Categrisatin It is pssible that there might be imprtant learning frm a patient s death even if death was unavidable. The care shuld be categrised using Cnfidential Enquiry int Stillbirths in Infancy (CESDI). Deaths are classified accrding t CESDI as fllws: Grade 0-Unavidable Death, N Subptimal Care. Grade 1-Unavidable Death, Subptimal care, but different management wuld nt have made a difference t the utcme. Grade 2-Pssibly Avidable Death, Subptimal care, but different care Might have affected the utcme. Grade 3- Prbable Avidable Death, Subptimal care, different care WOULD REASONABLY BE EXPECTED t have affected the utcme. Assessment f cding shuld be part f the case ntes review but the primary fcus shuld be t prvide assurance n quality f care. V4 Oct 17 3

4 4.4 Death certificatin The prcess f certifying, recrding and registering death, the causes f death and any cncerns abut the care prvided. This prcess includes identifying deaths fr referral t the crner. 4.5 Patient Safety Incident The Trust (and NPSA) definitin f a Patient Safety Incident is: Any unintended r unexpected incident(s) that culd have r did lead t harm fr ne r mre persns receiving NHS funded healthcare The Trust Learning Event Ntificatin (LERN) Plicy requires all patient safety incidents, including near miss and n harm events, t be recrded n a LERN frm and investigated accrdingly. Where a Retrspective case recrd review identifies that a patient safety incident has ccurred (Grades 2-3) then a LERN Frm shuld be cmpleted in accrdance with the LERN Plicy. Grade 2 and 3 cases shuld als be cnsidered as ptential serius incidents in line with the Trust Serius Incident (SI) reprting framewrk. 4.6 Serius Incident Serius Incidents in healthcare are adverse events, where the cnsequences t patients, families and carers, staff r rganisatins are s significant, r the ptential fr learning is s great, that a heightened level f respnse is justified. Serius Incidents include acts r missins in care that result in unexpected r avidable death, unexpected r avidable injury resulting in serius harm including thse where the injury required treatment t prevent death r serius harm abuse, Never Events, incidents that prevent (r threaten t prevent) an rganisatin s ability t cntinue t deliver an acceptable quality f healthcare services, and incidents that cause widespread public cncern resulting in a lss f cnfidence in healthcare services. See the SI Tlkit fr further infrmatin: Investigatin A systematic analysis f what happened, hw it happened and why, usually fllwing an adverse event when significant cncerns exist abut the care prvided. Investigatins draw n evidence, including physical evidence, witness accunts, rganisatinal plicies, prcedures, guidance, gd practice and bservatin, t identify prblems in care r service delivery that preceded an incident and t understand hw and why thse prblems ccurred. The prcess aims t identify what may need t change in service prvisin r care delivery t reduce the risk f similar events in the future. Investigatin can be triggered by, and fllw, case recrd review, r may be initiated withut a case recrd review happening first. See RCA Tlkit fr further infrmatin. V4 Oct 17 4

5 4.8 End f Life Care It may be that after admissin, a patient underges active treatment initially, and later a decisin is made t fcus n symptm cntrl and dignity( ie t prvide end f life care). Occasinally, active treatment may ccur simultaneusly with palliative r end f life care. A patient may nly be recgnised t be dying smetime after the admissin. Hwever, this plicy is intended t aid learning frm any phase f active treatment and end f life care. Please nte if it has been decided that a patient is nt fr attempted cardipulmnary resuscitatin (i.e has a AAND frm) this des NOT preclude active management and des nt mean the patient s death shuld be assumed t have been unavidable. Key questins in the End f Life Sectin f the case review are: In retrspect culd it have been identified earlier that patient was dying? (fr example aviding unnecessary r inapprpriate tests r treatment in the last days f life, r allwing mre time fr discussins with the patient r the patient s family r friends) Were any cncerns abut the manner f the patient s death raised? Clear escalatin plan r ceiling f treatment dcumented? 5.0 Rles and Respnsibilities Rle Chief executive Nn-executive directrs (including the rle f a lead nn-executive directr in taking versight f prgress in implementing the Learning frm Deaths agenda) Respnsibilities Overall respnsibility fr implementing the plicy Nn-executive directr respnsibilities relating t the framewrk include: understanding the review prcess: ensuring the prcesses fr reviewing and learning frm deaths are rbust and can withstand external scrutiny champining quality imprvement that leads t actins that imprve patient safety assuring published infrmatin: that it fairly and accurately reflects the rganisatin's apprach, achievements and challenges. Medical Directr Delegated respnsibility fr implementing the plicy and Bard level lead fr the learning frm deaths agenda. The Medical Directr is chair f the Trust Mrtality Surveillance Grup Trust Mrtality lead Cnsultant lead fr the Trust Mrtality agenda. Respnsible t the Medical Directr V4 Oct 17 5

6 Rle Respnsibilities Learning disability lead Act as trained LeDeR Learning Disability Mrtality Reviewer Other specific rles All staff See belw See belw Clinical Directrs are respnsible fr: Ensuring that there is a frmal M&M meeting fr all specialties within their Directrates Establishing reprting prcesses frm M&Ms t the Directrate/Care Grup Clinical Gvernance Grup. Ensuring that issues, trends and actins are rutinely reprted t the Directrate/Care Grup Clinical Gvernance Grup as a standing agenda item. Ensuring that significant risk issues arising frm Mrtality Reviews are raised at the Trust Mrtality Surveillance Grup, QARC as apprpriate. Ensuring that significant risk issues arising frm Mrtality Reviews are raised at TMB if required. Ensuring that Grade 2 and 3 cases are reprted and investigated in accrdance with the Trust LERN and SI plicy. Chairs f Directrate/Specialty Mrtality Meetings Clinical Directrs will ensure that Mrtality and Mrbidity (M&M) Chairs are nminated and apprpriately jb planned within the directrate. In sme cases the M&M chair will cver the whle directrate, in ther cases speciality level leads have been appinted. The M&M Chair is respnsible fr ensuring: The facilitatin f case nte reviews (using the standard emrtality Review prfrma) f all deceased inpatients as triggered by ntificatin frm the emrtality electrnic system All inpatient deaths are reviewed and dcumented using the emrtality Review prfrma. All reviews are cmpleted electrnically and saved t the central database All deaths are discussed at the speciality M&M meeting and key learning pints and actin plans agreed and dcumented. Crss speciality advice is sught as apprpriate t the mrtality review e.g. ITU, palliative care, radilgy The findings and actin plans f the speciality M&M meeting are reprted int the Directrate/Care Grup Clinical Gvernance Grup Significant trends, cncerns r risk issues frm mrtality reviews are reprted t the Trust Mrtality Surveillance Grup as apprpriate Significant risk issues are flagged t the directrate Quality and Risk Lead and Clinical Directr fr reprting t QARC and/r TMB. Escalatin f any specific areas f significant cncern e.g. serius incidents identified frm a review, using ther Trust plicies where apprpriate. Ensure 2-3 grade cases are reprted as LERNs. V4 Oct 17 6

7 Medical Staff All cnsultant medical staff shuld participate in the M&M prcess fr any patients under their respnsibility. All cnsultants undertaking mrtality reviews are respnsible fr cntacting clinicians in ther specialities where relevant t the patients admissin and care. E.g. ITU, palliative care, radilgy. All medical staff shuld participate in all M&M reviews that are relevant t their practice. All junir dctrs shuld be actively encuraged t participate in Mrtality reviews, case presentatins and M&M meetings. Nurses, Allied Health Prfessinals and Other Clinical Staff All relevant healthcare prfessinals shuld be invlved in learning frm M&M reviews. Feedback may be n an individual case review r via key learning pints and/r trends discussed and/r cascaded via relevant Trust r directrate/care Grup clinical gvernance meetings, team meetings r ther similar frum. 6.0 Gvernance Structures Cmmittee Trust Bard Respnsibilities The Bard f Directrs are respnsible fr meeting the requirements (Annex A and B f the Natinal Guidance n Learning frm Deaths. See Appendix 1 The Bard are respnsible fr reviewing the quarterly reprt prvided by the Mrtality Surveillance Grup (in accrdance with Natinal requirements) Mrtality Surveillance Grup See Appendix 2 Healthcare Assurance Cmmittee Quality and Risk Cmmittee Mrtality Meetings (Directrate/Specialty) T receive a quarterly reprt frm the Mrtality Surveillance Grup T receive reprts frm directrate gvernance meetings and review any learning frm mrtality reviews. See belw V4 Oct 17 7

8 Mrtality and Mrbidity (M&M) Meeting Mrtality (r M&M) meetings must be held fr all named clinical specialities listed in Appendix 3. Meetings may als be held in ther specialities such as critical care and Interventinal Radilgy. M&M chairs may als be asked t cntribute t reviews verseen by anther speciality. The Trust plicy is t ensure: There is cnsistency f apprach t the review f inpatient mrtality thrughut the Trust via the use f a standardised prfrma (Retrspective Case Recrd Review). The utputs f any mrtality reviews are clearly dcumented, actin plans agreed and learning pints disseminated. Feedback frm Mrtality meetings is rutinely discussed at the Mrtality Surveillance Grup. Feedback frm Mrtality meetings is rutinely discussed at the Directrate Clinical Gvernance Grup r similar named frum. Each Speciality M&M meeting shuld have the fllwing minimum standards: A nminated (identified) Chair At least quarterly meetings Multi-disciplinary and multi-prfessinal membership All death reviews must be recrded via the Trust electrnic Mrtality Review Prfrma Any learning pints and actins frm each meeting are recrded and cascaded in accrdance with the gvernance arrangements shwn in Appendix 3. All grade 2 and 3 deaths are reprted immediately as a LERN Meetings shuld cmprise a multi-disciplinary grup reviewing and discussing clinical cases in relatin t clinical care, cmplicatins and/r death; ideally and where pssible, in the cntext f existing utcme data and related infrmatin (e.g. cmplaints, Dr Fster reprts r ther benchmarks r standards). A specific requirement f the Francis Reprt (2013) is that M&M meetings shuld include senir and junir dctrs, nurses and ther Allied Health Prfessinals as apprpriate fr that speciality. The Chair f the meeting shuld ensure that there is a prcess fr ensuring any findings are shared and that any actins are suitably recrded, c-rdinated and cascaded thrughut the speciality. A standard M&M meeting template is available via the e-mrtality prcess. 7.0 The prcess fr recrding deaths in care Fr additinal details refer t the fllwing: Care After Death Plicy (previusly knwn as the last ffices plicy) Mrtuary Plicy. Death in the Operating Theatre Theatre.pdf V4 Oct 17 8

9 Plicy fr the Deactivatin f Implantable Cardiverter Defibrillatrs (ICD) twards the end f life and fllwing death ED Child death/anticipated death prcess fr all 0-18yrs Prcedure fr the death f a patient in the Burnemuth Transplant Unit fllws ASCT autlgus stem cell transplantatin The next f kin will be infrmed f the death as sn as pssible after the verificatin/certificatin. Where there is n next f kin, the plice shuld be infrmed immediately. If there is any difficulty in cntacting the next f kin, the plice may be able t assist in lcating them and asking them t cntact the hspital. The next f kin/carer shuld be advised t cllect the cause f death certificate and prperty frm the general ffice during ffice hurs. They will be asked t phne General Office, after 10am, in rder t cnfirm that all prperty, and dcumentatin are ready fr cllectin. Cause f Death certificates CANNOT be cllected ut f hurs, at weekends r Bank Hlidays. Advice can be sught frm the General Office r the Site Manager [ut f hurs]. All deaths must be entered n ECamis within 30 minutes f the event. The cause f death certificate, deceased patient s ntes and prperty shuld be cmpleted in the General Office at Burnemuth [unless the patient is n the Macmillan Unit at Christchurch Hspital]. The Macmillan Unit patients have the dcumentatin cmpleted n the Macmillan Unit but the ntes are sent t General Office at Burnemuth. DEATHS CAN ONLY BE CERTIFIED BY A REGISTERED MEDICAL PRACTITIONER Medical staff must cmplete an eidf fr all deaths. 8. Selecting deaths fr case recrd review The Trust will undertake a retrspective case recrd review fr ALL inpatient deaths. This will include undertaking reviews t meet all f the specific categries f deaths mandated in the Learning frm Deaths framewrk and all categries listed in the Natinal Guidance n Learning frm Deaths) The Trust (via the Mrtality Surveillance Grup) will cntinuusly mnitr SHMI t review mrtality ratis f deaths within 30 days f discharge. A themed review will be cmmissined by MSG if any upward trend is nted. As required the Trust will respnd t requests frm ther rganisatins t review the care prvided t peple wh are its current r past patients but wh were nt under its direct care at time f death. The Trust will frward details f any Learning Disability deaths t the LeDER prgramme. V4 Oct 17 9

10 9. Review methdlgy The Trust has develped a standard emrtality/ Retrspective Case Recrd Review Frm All sectins f the emrtality Review Frm shuld be cmpleted fr all inpatient deaths. Patient grup Methdlgy Reviewer Timescale fr review Where inf/utput will be saved Adult inpatient Structured case nte review by lead, presentatin t speciality/directrate Mrtality meeting fr Peer review and agreement n grading, actins and learning pints Lead cnsultant 60 days fr cnsultant review e-mrtality Learning disability The Trust will adpt the LeDeR methd t review the care f individuals with learning disabilities. CPI flags and cding will be used t flag patients with learning disabilities s their care can be reviewed. Lead cnsultant (internal review) CCG appinted Natinal LeDER prgramme investigatr (external review) 60 days fr internal cnsultant review e-mrtality Child (under 18) Reviews f these deaths are mandatry and will be undertaken in accrdance with Wrking tgether t safeguard children 1 (2015) and the current child death verview panel prcesses. Safeguarding lead fr Children 60 days fr cnsultant review e-mrtality and SI Prcess (Datix) Perinatal and maternity All perinatal deaths will be reviewed, using the new perinatal mrtality review tl 2 nce available. Maternal deaths and many perinatal deaths are very likely t meet the definitin f a Serius Incident and if applicable will be investigated accrdingly Lead investigatr Natinal inquiry in t maternal death. 60 days fr internal review e-mrtality and SI Prcess (Datix) All emrtality reviews f in-hspital deaths are expected t be cmpleted by the lead cnsultant within 60 days f patient s death. Review at a relevant M&M meeting shuld be within 3-4 mnths V4 Oct 17 10

11 10. Staff training and supprt 10.1 Training n the Death Certificatin prcess is cvered n Junir Dctrs inductin and cre teaching prgramme :1 training n use f the e-mrtality system is prvided by the IT Training Department The Trust Mrtality lead and the Assciate Directr fr Quality and Risk have received Ryal Cllege f Physicians (RCP) Structured Case Recrd (SCR) Training and will lead f any cascade f training as apprpriate The Quality and Risk Department prvide regular Rt Cause Analysis (RCA) training. Sessins cver prcesses applicable t grade 2 and 3 mrtality review investigatins. Sessins can be bked via ESR and BEAT The Trust has trained a number f senir leads (including the Medical Directr, Assciate Medical Directr, Clinical Directrs fr Surgery, ED and cardilgy, Head f Midwifery, Heads f Nursing and Quality and the Assciate Directr fr Quality and Risk) t chair Serius Incident investigatin panels. 11. Selecting deaths fr investigatin 11.1 Where a Retrspective case recrd review identifies that a patient safety incident has ccurred (Grades 2-3) then a LERN Frm shuld be cmpleted in accrdance with the LERN Plicy Grade 2 and 3 cases shuld als be cnsidered as ptential serius incidents in line with the Trust Serius Incident (SI) reprting framewrk. 12. Reviewing utputs frm review and investigatin t infrm quality imprvement 12.1 The findings f mrtality reviews and investigatins will be used t infrm quality imprvement wrk acrss the Trust and supprt the Trust Quality pririties as set ut in the Quality Accunt and Quality Strategy Additinal actins include: Feedback frm Mrtality leads t the Mrtality Surveillance Grup and publicatin f a quarterly mrtality newsletter t share key learning pints fr Trust wide disseminatin Feedback frm Directrate Gvernance leads t the Quality and Risk Cmmittee and inclusin f any learning pints fr Trust wide actin and/r disseminatin in the QARC Tp 10 Shared learning with any linked Quality Imprvement r Clinical Audit wrk/activity within the Trust e.g. via the Annual Patient Safety and Quality Imprvement Cnference case study presentatin and/r pster Sharing learning as part f the Wessex AHSN Sharing learning via the Drset and WH CCG Patient Safety Netwrks Quarterly reprting n learning frm mrtality reviews t the public part f the Bard f Directrs meeting Receiving and discussing findings frm any natinal audit prgrammes at MSG and disseminatin via meeting papers t mrtality leads. V4 Oct 17 11

12 13. Presenting relevant infrmatin in bard reprts 13.1 The Mrtality Surveillance Grup will prvide a quarterly reprt t part 1 (public part) f the Bard f Directrs summarising the details f the number f structured mrtality case nte reviews cmpleted and the gradings recrded The Mrtality Surveillance Grup will prvide a quarterly reprt t HAC summarising the details f meetings held, cmpliance with the emrtality review prcess and findings f reviews carried ut and actins taken as a result f lessns learnt Directrates will be respnsible fr prviding assurance n implementatin f the Mrtality Review prcess as part f Directrate/Care Grup gvernance meetings A standard suite f e Mrtality system reprts will be used t supprt mnitring by specialities and relevant grups and cmmittees. 14. Supprting and invlving families and carers 14.1 The Trust will ensure the fllwing key principles are met during the mrtality review prcess: bereaved families and carers are treated as equal partners fllwing a bereavement; bereaved families and carers will always receive a clear, hnest, cmpassinate and sensitive respnse in a sympathetic envirnment; bereaved families and carers receive a high standard f bereavement care which respects cnfidentiality, values, culture and beliefs, including being ffered apprpriate supprt. bereaved families and carers are infrmed f their right t raise cncerns abut the quality f care prvided t their lved ne; bereaved families and carers views are used t infrm decisins abut whether a detailed serius incident investigatin is needed; bereaved families and carers receive timely, respnsive cntact and supprt in all aspects f an investigatin prcess, with a single pint f cntact and liaisn; 14.2 All bereaved families will be prvided with written infrmatin (via the Trust Bereavement patient infrmatin leaflet) infrming them that all deaths are reviewed and asking them if they have any questins r cncerns abut the death f their relative At all apprpriate stages, families shuld als be asked what feedback they might want fllwing the review and any specific questins r cncerns they wuld like answered Additinal guidance n infrming, supprting and invlving families is als detailed in the Trust SI and RCA Tlkit and Duty f Candur Tlkit Supprting and invlving staff 15.1 Staff affected by the death f patients are able t seek supprt frm: Line manager Clinical and/r Educatinal Supervisr Occupatinal Health Chaplaincy V4 Oct 17 12

13 Quality and Risk Team Unin representative i.e. RCN, Unisn 15.2 The Trust Emplyee Assistance Prgramme (EAP) is prvided by Care First. Care First, is a cmplete wrkplace supprt service. The services are available nline, and via a Freephne number 24Hrs a day 365 days f the year. Access t infrmatin, cunselling, emtinal supprt and wellbeing is free fr all emplyees. It is cmpletely cnfidential. The free EAP phne service, is number frm a landline, r #685 as the Trust shrtcut. Full details f the service are available n the Health and Well Being pages f the intranet Other surces f infrmatin r supprt include: All mrtality reviews fllwing the Trust SI prcess will recrd (as part f the scping meeting and final panel reprt) that staff supprt has been prvided apprpriately Dcument Cntrl, Archiving and Review f this Plicy 16.1 Dcument Cntrl The plicy will be updated and reviewed in accrdance with the Trust Dcument Cntrl Plicy Archiving The Plicy will be stred n the Trust s Intranet as a live versin. Once updated an archive cpy will be stred n the Trust Dcument Management System in accrdance with the Trust Dcument Cntrl Plicy Review The plicy will be reviewed tw yearly by the Mrtality Surveillance Grup. V4 Oct 17 13

14 Appendix 1 - Natinal Guidance n Learning frm Deaths, Annex A and B - Bard Leadership and the rle f Nn-Executive Directrs Bard f Directrs The bard shuld ensure that their rganisatin: has an existing bard-level leader acting as patient safety directr t take respnsibility fr the learning frm deaths agenda and an existing nn-executive directr t take versight f prgress; pays particular attentin t the care f patients with a learning disability r mental health needs; has a systematic apprach t identifying thse deaths requiring review and selecting ther patients whse care they will review; adpts a rbust and effective methdlgy fr case recrd reviews f all selected deaths (including engagement with the LeDeR prgramme) t identify any cncerns r lapses in care likely t have cntributed t, r caused, a death and pssible areas fr imprvement, with the utcme dcumented; ensures case recrd reviews and investigatins are carried ut t a high quality, acknwledging the primary rle f system factrs within r beynd the rganisatin rather than individual errrs in the prblems that generally ccur; ensures that mrtality reprting in relatin t deaths, reviews, investigatins and learning is regularly prvided t the bard. The reprting shuld be discussed at the public sectin f the bard level with data suitably annymised; ensures that learning frm reviews and investigatins is acted n t sustainably change clinical and rganisatinal practice and imprve care, and reprted in annual Quality Accunts; shares relevant learning acrss the rganisatin and with ther services where the insight gained culd be useful; ensures sufficient numbers f nminated staff have apprpriate skills thrugh specialist training and prtected time as part f their cntracted hurs t review and investigate deaths; ffers timely, cmpassinate and meaningful engagement with bereaved families and carers in relatin t all stages f respnding t a death; acknwledges that an independent investigatin may in sme circumstances be warranted, fr example, in cases where it will be difficult fr an rganisatin t cnduct an bjective investigatin wrk with cmmissiners t review and imprve their respective lcal appraches fllwing the death f peple receiving care frm their services. Nn-Executive Directrs All Trust directrs, executive and nn-executive, have a respnsibility t cnstructively challenge the decisins f the bard and help develp prpsals n strategy. V4 Oct 17 14

15 Nn-executive directrs, in particular, have a duty t ensure that such challenge is made. They play a crucial rle in bringing an independent perspective t the bardrm and shuld scrutinise the perfrmance f the prvider s management in meeting agreed gals and bjectives and mnitr the reprting f perfrmance. Nn-executive directrs shuld satisfy themselves as t the integrity f financial, clinical and ther infrmatin, and that clinical quality cntrls and systems f risk management, fr example, are rbust and defensible. The rles and respnsibilities f nn-executive directrs include: Understanding the prcess: ensure the prcesses in place are rbust and can withstand external scrutiny, by prviding challenge and supprt. Fr example: be curius abut the accuracy f data and understand hw it is generated; wh is generating it, hw are they ding this, is the apprach cnsistent acrss the Trust? seek similar data and trend infrmatin frm peer prviders, t help challenge ptential fr imprvements, but understand limitatins f any direct cmparisns; ensure timely reviews/investigatins (what is the interval between death and review r investigatin?), calibre f reviewer and quality f the review r investigatin; cnsider whether the Care Recrd Review prcess is bjective, cnducted by clinicians nt directly invlved in the care f the deceased? are deaths f peple with learning disabilities reviewed accrding t the LeDeR methdlgy? cnsider the gvernance and crdinatin f respnses t reviews/investigatins wh is respnsible fr preparing the reprt, d prblems in care identified as being likely t have cntributed t a death feed int the rganisatin s Serius Incident prcesses? Champin and supprt learning and quality imprvement such as: ensuring the rganisatin has a lng-term visin and strategy fr learning and imprvement and is actively wrking twards this; understanding the learning being generated, including frm where deaths may be expected but the quality f care culd have been better; understanding hw the learning frm things ging wrng is translated int sustainable effective actin that measurably reduces the risks t patients - ensuring that learning and imprvements are reprted t the bard and relevant prviders; supprting any changes in clinical practice that are needed t imprve care resulting frm this learning; ensuring families and carers are invlved reviews and investigatins, and that nminated staff have adequate training and prtected time t undertake these prcesses; paying attentin t the prvisin f best practice and hw the learning frm this can be mre bradly implemented. Assure published infrmatin; ensure that infrmatin published is a fair and accurate reflectin f the achievements and challenges, such as: ensuring that infrmatin presented in bard papers is fit fr publicatin i.e. it is meaningful, accurate, timely, prprtinate and supprts imprvement; checking timely quarterly publicatin, in line with the Quality Accunts regulatins and guidance; checking that arrangements are in place t invite, gather and act n stakehlder feedback n a quarter by quarter basis; ensuring the rganisatin can demnstrate t stakehlders that this is what we said we wuld d, and this is what we did (learning and actin), and explain the impact f the quality imprvement actins. V4 Oct 17 15

16 Appendix 2 MORTALITY SURVEILLANCE GROUP MEETING TERMS OF REFERENCE The Mrtality Grup Meeting The Grup is a wrking grup established by and respnsible t the Healthcare Assurance Cmmittee. The Grup serves t ensure that there is an effective framewrk within which assurances can be given acrss the fllwing areas f business. 1. Membership 1.1 The Cmmittee Chairman (the Chairman ) shall be the Medical Directr. In the absence f the Chairman the Deputy Chair shall be the Clinical Lead fr Mrtality. In the absence f bth the Chair and Deputy Chair the Assciate Directr f Service Develpment will act as Chair. 1.2 Standing members f the Cmmittee shall include Medical Directr; Nn-Executive Directr; Assciate Directr f Service Develpment; Assciate Directr - Clinical Gvernance; Clinical Lead fr Mrtality; Senir Infrmatin Analyst; Clinical Effectiveness Manager; Service Develpment & Cding Manager; Deputy Directr f Nursing, Head f Nursing & Quality; Claims and Inquest Manager; Public Gvernr and M&M leads fr specialties acrss Trust. See Appendix Invited members fr specific issues wuld include Directr f Service Develpment; General Office Manager and Senir Analyst frm Dr Fster Intelligence. 1.4 Other individuals may be invited t attend fr all r part f any meeting, as and when apprpriate. 1.5 It is expected that members attend a minimum f 8 meetings per year and nminate a deputy fr the ccasins they cannt attend unless agreed therwise. 2. Secretary The PA t the Medical Directr (the Secretary ) r their nminee shall act as the secretary f the Cmmittee. 3. Qurum The qurum necessary fr the transactin f business shall be 4 members. A duly cnvened meeting f the Cmmittee at which a qurum is present shall be cmpetent t exercise all r any f the authrities, pwers and discretins vested in r exercisable by the Cmmittee. 4. Frequency f Meetings The Cmmittee shall meet mnthly. 5. Ntice f Meetings V4 Oct 17 16

17 5.1 Unless therwise agreed, ntice f each meeting cnfirming the venue, time and date tgether with an agenda f items t be discussed, shall be frwarded t each member f the Cmmittee and any ther persn required befre the date f the meeting. Supprting papers shall be sent t Cmmittee members and t ther attendees as apprpriate, at the same time. 6. Minutes f Meetings 7. Duties 6.1 The Secretary shall minute the prceedings and reslutins f all meetings f the Cmmittee, including recrding the names f thse present and in attendance. 6.2 Minutes f Cmmittee meetings shall be circulated prmptly t all members f the Cmmittee. The duties f the Cmmittee can be categrised as fllws: 7.1 Internal Cntrl, Risk Management & Assurance T review mnthly death certificatin reprts and cmpare with e-idf primary diagnsis cding t ensure accuracy f cding by exceptin T review Dr Fster CUSUM r relative risk reprts mnthly fr HSMR, SHMI and high risk cnditins, and highlight areas fr specific cding and clinical review. T review e-mrtality and extract data fr the verall cmpletin rate, categrizatin f death, avidable mrtality and mrtality in learning disability T highlight ptential areas f risk t the Healthcare Assurance Cmmittee T identify any ptential actual r ptential Dr Fster r Care Quality Cmmissin Alerts and t make recmmendatins fr actin t Healthcare Assurance and Bard f Directrs as required T review any cding prcedures that may influence the Trusts CUSUM r relative risk results and recmmends any actin as necessary t ensure data accuracy T receive reprts frm all the specialty M&M r gvernance meetings and discuss cases relating t death fllwing interventin/prcedure r unexpected deaths and disseminate learning acrss the Trust T review the Trusts verall Standardised Mrtality Rati (mnthly) and review speciality mrtality rates (by tp HRG grups) n a rlling prgramme. 7.2 External Validatin & Assessment T review any submissins t external agencies where the reprt may affect the Trusts reputatin, psitin r quality ratings n patient safety, mrtality r quality f care perfrmance. 7.3 Annual Reprts and Plans V4 Oct 17 17

18 7.3.1 T prvide a quarterly reprt t the (as part f the Quality Accunt) Healthcare Assurance Cmmittee n reviews cmpleted and actins taken t imprve data quality and hspital standardised mrtality rates. 7.4 Natinal Guidance and Plicy T identify any training requirements in relatin t the use, analysis and investigatin f Dr Fster and CQC Mrtality Data and reprts and e- mrtality review. 8. Reprting Respnsibilities 9. Other 8.1 The Medical Directr shall reprt quarterly t the public part f Bard f Directrs meeting. This shuld include numbers f mrtality metrics, numbers f deaths, and numbers f deaths reviewed by mnth and thse that have been graded as having avidable features and mrtality in learning disability. 8.2 The Cmmittee shall reprt quarterly t the Healthcare Assurance Cmmittee. A reprt shall be presented by the Medical Directr. The Cmmittee shall: 9.1 Give due cnsideratin t laws and regulatins and the prvisins f the Cde f Gvernance. 9.2 Oversee any investigatin f activities which are within its terms f reference. 9.3 At least nce a year review terms f reference and attendance t ensure it is perating at maximum effectiveness and recmmend any changes it cnsiders necessary t the Healthcare Assurance Cmmittee fr apprval. 10. Authrity The Cmmittee is authrised: 10.1 T seek any infrmatin it requires frm any emplyee f the Trust in rder t perfrm its duties T btain, at the Trust s expense, utside legal r ther prfessinal advice n any matter within its Terms f Reference. V4 Oct 17 18

19 APPENDIX 1 Directrate Clinical Gvernance Key Perfrmance Indicatrs Regular Reprts Received by Mrtality Surveillance Grup Quality Indicatrs Frequency f Reprt Reprted by Dr Fster HSMR reprts (CUSUM, Relative Risk), crude mrtality rates, deaths within 36 hurs f admissin, deaths in high risk grups. E-mrtality reviews. Mnthly Dr Fster Intelligence Reprt Quarterly CQC Mrtality Alerts As Alerts Arise CQC Insight Reprt Mnthly Trust Clinical Lead fr Mrtality and Senir Infrmatin Analyst Dr Fster Infrmatin Analyst Clinical Effectiveness Manager and Trust Clinical Lead fr the Mrtality Assciate Directr fr Gvernanace Cding quality reprts Quarterly reprts frm speciality M&M meetings By exceptin Quarterly Cding Manager Regular Reprts Prvided t Healthcare Assurance Cmmittee Quality Indicatrs Frequency f Reprt Prvided by Prgress n review f CQC Mrtality reprts and reviews Quarterly Medical Directr Significant risks raised fllwing review f Dr Fster data Quarterly Medical Directr Regular Reprts Prvided t Bard f Directrs Quality Indicatrs Frequency f Reprt Prvided by Prgress n review f CQC Mrtality reprts and reviews Quarterly Medical Directr Mrtality matrix, mrtality review cmpletin rate, avidable mrtality, Quarterly Medical Directr V4 Oct 17 19

20 mrtality in learning disability, key learning themes frm mrtality reviews. V4 Oct 17 20

21 APPENDIX 2 M&M Leads M&M Chairs Speciality / Department / Directrate Gastrenterlgy Diabetes & Endcrine Cardilgy Respiratry Acute Medicine Older Peple s Medicine Strke ED Orthpaedics Vascular Surgery Ophthalmlgy Haematlgy Urlgy Anaesthetics ITU Radilgy Palliative Medicine M&M Lead Safa Al-Shamma Gergina Page (Quarterly) Jehangir Din Dawn Edwards Abbey Banfield Sue Hazel Kamy Thavanesan Matthew Baker (Quarterly) Richard Hartley Jhn Oakes Nick Baylem Catherine Marsh (n invitatin) Helen McCarthy (Quarterly) Jshua Phillips Lynsey Wdward Jules Cranshaw David Beckett (Quarterly) Helen Whalley V4 Oct 17 21

22 APPENDIX 3 Mrtality Gvernance Framewrk V4 Oct 17 22

23 Appendix 4 MORTALITY REVIEW eform V4 Oct 17 23

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28 EQUALITY IMPACT ASSESSMENT SCREENING FORM 1. Title f dcument/service fr assessment Mrtality Review Plicy 2. Date f assessment 21/9/14 3. Date fr review 21/9/16 4. Directrate/Service Risk Management 5. Apprval Cmmittee Mrtality Grup/MICE/TMB Yes/N Ratinale 6. Des the dcument/service affect ne grup less r mre favurably than anther n the basis f: N Race Gender (including transgender) Religin r belief Sexual rientatin, t include hetersexual, lesbian, gay and bisexual peple Age Disability learning disabilities, physical disabilities, sensry impairment and mental health issues Marriage and Civil Partnership Pregnancy and Maternity 7. Des this dcument affect an individual s human rights? 8. If yu have identified ptential discriminatin, are the exceptins valid, legal and/r justified? N N N N N N N N N 9. If the answers t any f the abve questins is yes then: Demnstrate that such a disadvantage r advantage can be justified r is valid Adjust the plicy t remve disadvantage identified r better prmte equality If neither f the abve pssible, submit t Diversity Cmmittee fr review. Tick Ratinale 10. Screener(s) Print name Janne Sims 11. Date Plicy apprved by Cmmittee Sept Upn cmpletin f the screening and apprval by Cmmittee, this dcument shuld be upladed t papertrail. V4 Oct 17 28