Learning From Patient Deaths Policy Version One Applies to:- All employees Committee for Approval Quality and Safety Committee Date of Approval 20 September 2017 Review Date September 2020 Title of Lead Manager Medical Director Policy Author Deputy Medical Director Summary key points:- The process that THE TRUST will undertake to review death in certain circumstances, as described in the Policy. The Trust is required to ensure those deaths that meet with the criteria are reviewed and reported externally.
CONTENTS Page 1 Introduction 3 2 Scope 3 3 Purpose 4 4 Definitions 4 5 Duties 6 6 Reporting and Recording 8 7 Screening Tool 8 8 Family and Carer Involvement 9 9 Equality Impact Assessment 9 10 Training Requirements 9 11 References 9 12 Monitoring Compliance 9 Appendix 1 Monitoring Compliance 10 Appendix 2 Screening Tool 11 Version Control Version No Type of Change Date Description of change 1 New September 2017 2 3 4 2/10
Learning from Patient Deaths INTRODUCTION 1. Learning from the deaths of people in our care can help Wirral NHS Foundation Trust (the Trust) improve the quality of the care we provide to patients and their families, and identify where this care could be improved. 2. 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 that 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. 3. 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. 4. This national guidance requires Trusts to: Have a Leaning from Deaths Policy approved and published by the end of September 2017 reflecting the guidance and setting out how the Trust responds to and learns from, deaths of patients who die under its management and care and includes deaths of individuals with a learning disability and children Publish information on deaths, reviews and investigations via an agenda item and paper to public Board meetings Have a considered approach to the engagement of families and carers in the mortality review process Publish evidence of learning and actions taken as a result of the mortality review and learning from deaths process in the Trust s Quality Account from June 2018 5. This Policy sets out how the Trust will evaluate those deaths that form part of our Mortality Review process and what the criteria is for review, how this will be reported and a commitment to provide quarterly reports to the Mortality Review Group and an annual report to the Quality and Safety Committee and the Trust Board. 6. Mortality review is a means of identifying problems in healthcare and identifying areas of care which could be improved such as early recognition and escalation of the deteriorating patient, and provision of appropriate and timely end of life care. Reviews also often highlight aspects of excellent care, and it is important that learning from both areas of excellence, as well as those in need of improvement, is shared across the Trust. 7. This policy is about reflective learning from deaths that are considered within the remit of this policy. If a practitioner has immediate concerns regarding a patient death that was known to a trust service, this should be escalated immediately to their line manager. SCOPE The contents of the policy applies to all staff This policy applies to all staff whether they are employed by the trust permanently, temporarily, through an agency or bank arrangement, are students on placement, are party to joint working arrangements or are contractors delivering services on the trust s behalf. 3/10
PURPOSE 1. The trust will implement the requirements outlined in the Learning from Deaths framework as part of the organisation s existing procedures to learn and continually improve the quality of care provided to all patients. 2. This policy sets out the procedures for identifying, recording, reviewing and investigating the deaths of people in the care of the trust. 3. It describes how the trust will support people who have been bereaved by a death at the trust, and also how those people should expect to be informed about and involved in any further action taken to review and/or investigate the death. It also describes how the trust supports staff who may be affected by the death of someone in the trust s care. 4. It sets out how the trust will seek to learn from the care provided to patients who die, as part of its work to continually improve the quality of care it provides to all its patients. 5. To provide assurance to the Trust Board that any avoidable deaths identified where the Trust was in a position to influence the outcome brings about change in practice. 6. To provide an annual report based on quarterly reporting to the Quality and Safety Committee. 7. To ensure the Trust meets with national best practice guidance National Guidance on Learning from Deaths (03/17) where appropriate. 8. To give clarity as to the rationale behind the decision on which deaths will be reportable under this policy. 9. To support external reporting as required under the NHS England Serious Incident Framework. DEFINITIONS Definitions and explanations of any terms used are as follows: Patient includes all users of trust services Mortality review The process of reviewing the quality of care and assessing if the incident of patient death was avoidable. Case record review Is a desk top review of case notes using a screening tool (Appendix 2). Serious incident is reported on the Strategic Executive Information System (STEIS), which alerts NHS England, and is defined as an incident that occurred in relation to NHS funded services and care, resulting in one of the following: Unexpected or avoidable death Serious harm to patient, staff or member of the public A never event as defined by National Patient Safety Agency (NPSA). Unexpected Death - A death can be described as Unexpected if it was not anticipated to occur in the timeframe in which the individual died. The following gives a definition of this: cause of death is unknown death was violent or unnatural death was sudden and unexplained 4/10
Duty of candour is defined in the Francis report; The volunteering of all candour relevant information to persons who have or may have been harmed by the provision of services, whether or not the information has been requested and whether or not a complaint or a report about that provision has been made. Deaths that require reporting - Whilst a death may be unexpected it does not mean that the cause of death gives cause for concern or needs to be reported under this policy. Deaths in under 18 s (Children) - Infant or child (under 18) death reviews are mandatory and must be undertaken in accordance with Working Together to Safeguard Children (2015). These deaths do not fall into the scope of this policy and will be investigated under a different process e.g. Child Death Overview Panel. However, the Learning from Deaths Review Group will review the outputs from the Child Death Overview Panel to ensure any learning is embedded within The Trust. Deaths in over 18 s that require use of the screening tool (Appendix 2) - For the purpose of this Policy the deaths that fall under the remit of the Trust s Learning from Deaths policy are those deaths where the client has been seen in the past month where any of the following criteria apply: Unexpected death as above There has been a complaint by the deceased s family either internally through the Trust complaint process or externally There was concern raised by staff about patient care Deaths where bereaved families have expressed a concern Deaths in any service area where concerns have previously been raised (e.g. through audit or CQC inspection) Deaths in patients with a learning disability Any death where concern has been expressed about the quality of care delivered by the Trust including adult safeguarding concerns Any death occurring during delivery of care in a The Trust clinical setting (i.e. a patient dies in one of our clinical settings) Deaths declared as a Serious Incident by the Trust Deaths which occur as a result of a Never Event within the trust Staff should be aware that there are other reviews into both child and adult deaths that can take place. The purpose of this Policy is not to replace those existing processes but to ensure those cases which are not reviewed externally or which are but require attention by our own organisation are captured and reported as required. The following may be used, due to the circumstances, to review a child or adult death to identify learning: The Coroner Child Death Overview Panel (CDOP) Serious Case Review (SCR) Serious Incident (SI) under NHS England Guidelines Cases referred to a Coroner will be considered on an individual basis by review from the Medical Director and Director of Nursing. 5/10
DUTIES Medical Director The Trust s Executive Medical Director has responsibility within the Board of Directors for ensuring that the Trust has in place a robust process for Mortality Review and for leading the review process. The Medical Director also has oversight of the appropriate reporting of unexpected deaths both internally to other board members and externally via the Strategic Executive Information Reporting System (STEIS), to the trusts regional Care Quality Commission (CQC) link and to the regional NHSI quality team. The Medical Director is also responsible for ensuring that people who have been bereaved by a death at the trust are supported, and keeping them informed about and involved in any further action taken to review and/or investigate the death. The Medical Director will also ensure the trust supports staff who may be affected by the death of someone in the trust s care. The Medial Director is responsible for learning from the care provided to patients who die, as part of the trusts work to continually improve the quality of care it provides to all its patients. This includes the dissemination of any learning both internally and externally across the system as appropriate. Trust Board NHSI guidance (July 2017) states that the Board has responsibility to ensure that the following takes place: Robust systems are developed for recognising, reporting and reviewing or investigating deaths where appropriate Teams learn from problems identified in healthcare provided from reviewing different sources of information Effective, sustainable action is taken where key issues are identified Provision of visible, effective leadership to support staff to improve Ensure that needs and views of patients and the public are central to how the Trust operates. The Trust Board has overall responsibility for ensuring compliance with legal statutory, best practice including having an overview of this mortality review process and has knowledge of the learning that emerges from the reviews that drive improvements to care The Chief Executive has ultimate responsibility for ensuring that the Trust has robust policies and procedures in place for reviewing all incidents of mortality. An identified non executive lead is responsible to the board for providing assurance of the implementation of the national guidance. The Quality and Safety Committee The Quality and Safety Committee receives a quarterly report from the Mortality Review Group as well as an Annual Report which identifies learning and trends. The Chair of this group committee is the Medical Director who gives assurance to the Trust Board that The Trust is meeting its obligations and reports any areas of concern. 6/10
Mortality Review Group This group is responsible for the oversight of all aspects of Mortality review including initial data, the outcome of the initial screening process and any investigations undertaken. This group will meet quarterly to ensure timely review of data and learning and reports to the Quality and Safety Committee. The Director of Nursing and Quality Improvement They are responsible for working with the Medical Director to ensure appropriate reporting any identified unexpected deaths to the CCG through the Strategic Executive Information Reporting System (STEIS) within 2 working days of the unexpected death being identified and for informing the trusts regional Care Quality Commission (CQC) link and t the regional NHSI quality team. Head of Nursing and Patient Safety The Head of Nursing and Patient Safety is responsible for providing the Medical Director with a monthly report of all patient unexpected deaths notified to The Trust through the Datix reporting system for individuals aged over 18 years of age. Divisional Managers Divisional Managers are responsible for understanding the Trust s responsibilities in relation to Mortality Review and support the collation of this information and address actions identified through this process that will lead to improved patient care. They must make themselves aware of the relevant policies and guidance to ensure that all staff within their teams has access to: The appropriate means of recording a death that falls within the scope of the Trust s Mortality Review process and understanding of how to ensure this data is captured. Additional relevant training that is service specific. Clinical Supervision and informal and formal support Service Leads Service Leads are responsible for ensuring that:- Action plans are actioned timely, within agreed deadlines Team Leaders/Managers Team Leaders/Managers are responsible for ensuring:- All relevant staff contribute to the collection of data as required within agreed timescales All staff members are aware of the policy and the criteria for unexpected deaths Ensuring all unexpected deaths which meet the trust criteria are reported using the on-line Datix reporting system and complete an initial screening tool and uploaded to datix Clinical Staff All staff members are required to: Be aware of the policy, understand the trusts criteria for unexpected deaths To draw to the attention of their line manager any death that meets the criteria outlined in this policy To report the unexpected death on the Datix system To take part in any review of the case to ensure any required improvement in practice is identified. 7/10
REPORTING AND RECORDING Initial screening of information The Trust s Quality and Governance Service will provide a monthly report for the Medical Director of all patient unexpected deaths notified to The Trust through the Datix reporting system for individuals aged over 18 years of age. The service/team manager responsible for the service delivering care at the time of death will review the records using the trusts screening tool (Appendix 2) to ascertain if any the concerns are raised regarding the individuals death. The screening tool will be added to the datix incident report of the unexpected death. The Medical Director will review each completed screening tool with the Head of Nursing and Patient Safety. In cases where the screening tool responds with a Yes, a Root Cause Analysis (RCA) will be initiated by the Medical Director to ensure lessons learned and any change to practise takes place and can be implemented. Completed RCA s and action plans will be reported quarterly in the Learning from Patient Deaths Report which will be reported at the Quality and Safety Committee. Implementation and completion of the action plan will be monitored by the Mortality Review Group. Data sets The quarterly Mortality Review Group will review the following: The total number of unexpected deaths notified to The Trust Outcome of the screening tools completed (Appendix 2) Number of unexpected deaths that trigger an RCA Action plans and progress from RCAs The data will be presented via Learning from Deaths Dashboard and reported to the Quality and Safety Committee quarterly in the Learning from Deaths Report by the Medical Director. SCREENING TOOL The screening tool (Appendix 2) is to be used to help shape decision making in regards to whether the death fits with the criteria of the Learning from Deaths Policy. The screening tool is to be used in all cases where the criteria in this policy is met. If use of the tool identifies Yes to any questions then an RCA needs to be initiated by the Medical Director. FAMILY / CARER INVOLVEMENT The Trust will actively promote and work with staff to enable them to fully engage with the family, where appropriate, when a family member has died whilst receiving care to ensure that they are able to contribute to the RCA process as an equal partner. The approach that is expected from staff includes the following: Adopting an open and honest approach including early apology Include the family / carers in all appropriate aspects of the investigation including setting the terms of reference and explain the purpose of the investigation i.e. to identify learning so that improvements can be made 8/10
Keep the family/ carers informed throughout the process Offer the opportunity for the family / carers to ask questions, raise concerns and provide evidence Ensure that a coordinated approach is undertaken if the investigation involves a number of agencies. EQUALITY IMPACT ASSESSMENT (EIA) In line with the trusts commitment to meet its statutory requirements outlined in the Equality and Diversity Strategy each procedural document is screened using an Equality Impact Assessment (EIA) Screening Tool. This demonstrates the trusts commitment to equality and human rights by recognising that the experiences and needs of every individual are unique and strives to value and respect the diversity of staff, patients, carers and the public. EIA s support organisations to avoid discrimination on any grounds including age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex or sexual orientation. Carers are also protected from discrimination, as they are associated with people with a protected characteristic i.e. disabled people. Should staff become aware of any exclusions that do not comply with this statement would need to complete an incident form and an appropriate action plan put in place. TRAINING REQUIREMENTS All staff in the trust are required to comply with mandatory training as specified in the trusts Mandatory Training Matrix. Staff are also required to comply with job relevant training in their service as specified within their service training matrix and on the Learning and Development Section on the staffzone. REFERENCES National Guidance on learning from Deaths National Quality Board 1st Edition, (March 2017) Implementing the Learning from Deaths framework: key requirements for trust boards -NHS Improvement (July 2017) MONITORING COMPLIANCE See Appendix 1 9/10
Appendix one Process for monitoring compliance with Learning From Patient Deaths Policy Requirement to be monitored The total number of unexpected deaths notified to The Trust Outcome of the screening tools completed Number of unexpected deaths that trigger an RCA Action plans and progress from RCAs Process for monitoring Responsibility Frequency Responsibility for action plans Responsible Committee Mortality Review Group Medical Director Quarterly N/A Quality and Safety Mortality Review Group Medical Director Quarterly N/A Quality and Safety Mortality Review Group Medical Director Quarterly Medical Director Quality and Safety Policy Author is responsible for monitoring policy every two years report to be submitted to the relevant committee 10/11
Appendix 2 Screening Tool The Trust Learning from Deaths Screening Tool Unexpected Death Screening Tool NAME: DOB: GENDER: NHS NUMBER: ADDRESS: Service: The Trust Lead Clinician: Cause of death: Criteria for Case Record Review: If yes is answered to any points below the records will be reviewed by the Quality and Governance Service and the case refereed to the Medical Director for an RCA to be instigated. Criteria For Records Review Yes No/Not Applicable 1. Is the death is unexpected based on the Trusts criteria at page 4 and 5 of the policy? 2. Are there any concerns about the care received by the patient? This includes any part of the care received which fell below the standard expected by the trust e.g. avoidable pressure ulcer, avoidable healthcare acquired infection, failure to respond in a timely manner 3. Had concerns been raised previously about the care offered by the trust in this case by staff, the patient or service user or a member of their family? 4. Have you any concerns that this death was avoidable? 5. Is this case already subject to any internal or external investigation? 6. Have there been any complaints about care from the deceased person s family? 7. Has the death been reported through the national Strategic Information Reporting System 8. Has the death been reported to the coroner? 9. Did the patient have a learning disability? 10. Are there any other concerns that should be considered e.g. adult safeguarding concerns? 11/11