LEARNING FROM DEATHS POLICY

Issue number: 1st Edition LEARNING FROM DEATHS POLICY Author with contact details Dr Neil Mercer, Associate Medical Director for Clinical Governance Neil.mercer@aintree.nhs.uk tel. 529-5152 Original Issue date 26/09/2017 Issue Date: 26/09/2017. Review Date: 30/09/2020 Level Trust wide Location of Staff Trust wide Staff groups All clinical staff applicable to applicable to To be read In conjunction with / Associated Documents: Incident Reporting and Management Policy Investigation of Incidents, Complaints and Claims SOP Duty of candour checklist and flow chart (to be superceded by Duty of Candour SOP) Information Classification Label Unclassified Access to Information To access this document in another language or format please contact the policy author. Document Change History (changes from previous issues of policy (if appropriate) : Issue Number Page Changes made with rationale and impact on Date practice 1 N/A New Policy xx/xx/2017 CONTENTS TABLE OF CONTENTS Section Section Heading Page No 1. Summary Page 2 2 Introduction 2 3 Roles and Responsibilities 2 4 Content 3 5 Monitoring of Compliance 6 6 Equality, Diversity and Human Rights Statement 6 7 References 6 Appendices Page No 1 NQB Learning from Deaths 6 2 Avoidable Mortality Reduction Group Terms of Reference 6 Learning from Deaths Policy (1 st Edition, September 2017) Page 1 of 6

1.0 SUMMARY PAGE The Trust is committed to reducing the numbers of avoidable deaths within its patients. This aim is supported by having a formal mortality review process in place. The information gathered from this process is used to disseminate lessons learned across the Trust. The Avoidable Mortality Reduction Group (Chaired by the Medcial Director) oversees all improvement work relating to mortality. Directorates have local arrangements to meet the aims of this policy. The arrangements in each directorate ensure a suitable form of leadership for the mortality review process and that appropriate local mortality meetings are scheduled. This allows local learning. Divisional and Trust-wide learning will be managed through the Divisional teams and the Avoidable Mortality Reduction Group. The Trust aims to engage empathetically and effectively with bereaved families. The systems and processes in place have been developed to meet best practice/national guidance in learning from deaths. 2.0 INTRODUCTION This policy was written in response to the publication in March 2017 by The National Quality Board for the NHS of a paper entitled National Guidance on Learning from Deaths (hyperlink supplied in Appendix 1). It lays out the responsibilities of the trust as a whole and certain key groups and individuals within the trust in light of this guidance. This policy enables the Trust to formalise the process of mortality reviews after the majority of deaths, identify any avoidable factors and learn lessons from these deaths. 3.0 ROLES & RESPONSIBILITIES The Trust Board will maintain oversight of learning from deaths through receiving and discussing regular reports. These reports will be provided through the trust s standard assurance processes. A Non-executive Director will be assigned an oversight role with respect to learning from deaths and will provide appropriate challenge to the executive team on the subject. An Executive Team member will be the Patient Safety Director and they will take responsibility for the trust learning from deaths in the trust. They will chair the Avoidable Mortality Reduction Group (AMRG). This will usually be the Medical Director. The Patient Safety Director will have executive responsibility for ensuring that the organisation has a robust system in place for the meaningful review of deaths and which ensures a Trust wide process for learning from avoidable deaths. The Associate Medical Director for Clinical Governance and Deputy Medical Director(s) will support the Patient Safety Director in all areas of this work and act as the deputy Chair of the AMRG as required. The Avoidable Mortality Reduction Group will be responsible for complying with national guidance on learning from deaths. This will include the process of undertaking mortality reviews. The group will consider themes and trends identified from mortality reviews as part of the monthly Mortality Report. The group will ensure learning is disseminated across the trust from the results of these reviews. Terms of Reference and Membership included as Appendix 2. The Head of Performance will be responsible for producing the monthly mortality report. This will contain information on numbers and type of mortality reviews and trends/themes identified. When requested they will support the production of ad hoc reports allowing more detailed mortality investigations Learning from Deaths Policy (1 st Edition, September 2017) Page 2 of 6

The Aintree Business Intelligence (abi) Team will produce a monthly list of deaths; this will be circulated by email to consultants and mortality leads. They will develop suitable reporting systems to analyse the results of mortality reviews recorded within the Mortality Review System The Software Development Team will be responsible for developing the mortality review system. They will ensure it links to other trust data sources to minimize unnecessary data entry and that it imports accurate data from other systems. Clinical Directors will be responsible for ensuring their directorate has a nominated mortality lead(s) and that a suitable departmental meeting is in place to review deaths, consider mortality reviews and learn from the findings. Directorate mortality leads will be responsible for ensuring that mortality reviews are undertaken for patients that died in (or after care in) their directorate. They will organise and run their directorate s mortality review process and meetings to ensure that the meetings aim to identify weaknesses or failings in care, learn from these findings and undertake local actions to try to avoid the same things occurring in the future. They will also participate in the processes for Trustwide learning from mortality review findings. Directorate Mortality leads will usually be members of the AMRG representing their directorate. Consultants will be responsible for undertaking timely mortality reviews in line with the local arrangements within their directorate. These reviews will be conducted using the provided on-line mortality review system. They should aim to identify weaknesses or failings in clinical care; assess the avoidability of the death; seek to identify what could have been done differently and identify any lessons learned from the review (both local and trustwide). Trainee and non-consultant medical staff will assist in the mortality review process and take part in mortality review meetings under consultant supervision. Nursing and AHP staff should contribute to the mortality review process in line with their directorate s local processes and meeting arrangements. 4.0 CONTENT OF THE POLICY Engagement with bereaved families (including carers and other persons close to the deceased patient) All bereaved families will be supplied with a copy of the trust s bereavement support information (inpatient bereavement booklet). This will include a full range of support information for families after the death of loved one. It will include information on how to raise concerns relating to the care of their relative during their hospital stay. It will give information on the mortality review process and how to trigger a mortality review if they have concerns about their deceased relatives care. Communication with bereaved families will always be honest and open; in line with the Trust s values. Where there is a formal duty of candour identified in relation to a patient safety incident the appropriate steps will be taken to keep the bereaved family informed. The details of this are laid out in the Trust s Investigation of Incidents Complaints and Claims SOP. This is supplemented by two further documents: a duty of candour checklist and flow chart. These three documents are available by searching the document mamangement system for Duty of Candour. The duty of candour checklist and flow chart will be incorporated into a Duty of Candour SOP/Procedure/Policy during the lifetime of this policy. Directorate Mortality Review Processes & Meetings In all directorates a process for mortality reviews will be established by the Clinical Director and/or the Directorate Mortality Lead. This process will take account of the number of deaths in the directorate and the proportion requiring review (in line with this policy). The process will ensure that deaths are reviewed by a suitable senior clinician NOT INVOLVED in the patient s care. The arrangements to achieve this will vary depending upon the number of deaths and size of department. Learning from Deaths Policy (1 st Edition, September 2017) Page 3 of 6

Meeting frequency and duration will be chosen to allow discussion of all deaths where learning opportunities have been identified or the death was considered avoidable. This may necessitate a dedicated mortality meeting in some directorates; it may also be managed by including a mortality review section within an existing directorate audit, governance or other meeting. The default frequency should be monthly unless the directorate has very few deaths and can identify a suitable alternative frequency/pattern of meetings which achieves the aims of the mortality review process. Meetings do not need to discuss every death/every mortality review. Deaths which were unexpected, feature suboptimal care or were potentially avoidable should be considered; the aim of the discussion should be to elicit lessons learned which can be disseminated appropriately. Expected deaths where the process of care was satisfactory or better and where there were no lessons learned do not require discussion. Meetings should be minuted and an attendance register maintained. If a mortality review identifies a patient safety incident which could reasonably be considered to have influenced the outcome of the patient s care, the incident should be reported using the Trust s incident reporting system (Datix). The incident report can then be considered by the clinical risk team or escalated to the Weekly Meeting of Harm for a decision as to whether the case needs a formal incident investigation. When necessary this may include escalation up to and including a serious incident review in line with the Trust s Incident Reporting and Management Policy. http://intranet.aintree.nhs.uk/sites/dms/documents/incident%20reporting%20and%20management%20poli cy.pdf Completion of Mortality Reviews During the third week of each month the Aintree Business Intelligence Team will issue by email a list of all deaths in the trust during the previous month. The expectation of the trust is that this will allow the mortality review to be completed during the following month for potential discussion at the next month s mortality review meeting. Thus a death in January will be identified in February and should be discussed (if necessary) in March. Individual departments may choose to review deaths sooner than this using local systems to identify deaths. Individual patient deaths where concerns exist may be reviewed immediately if deemed necessary. Mortality reviews will be undertaken in all directorates in line with this policy. The review will be performed using the provided mortality review intranet website: http://informatics.aintree.nhs.uk/mortalityreview/home/index This online tool pre-populates with all available information about the patient, their admission and their death; it automatically reads date/time from the network and inserts the name of the reviewer from the active login information. It is therefore vital that the reviewer performs the review from a trust PC using their own login. During the life of this policy the review tool will be modified to bring it in line with latest best practice standards; the content will therefore change. It is the trust s intention to change to use the Structured Judgement Review tool piloted by the Royal College of Physicians once an online version is possible. Despite this the key emphasis during mortality reviews will be to summarise the admission, identify any suboptimal care, identify any elements of avoidability in the death, identify what if anything could have been done differently and suggest lessons to be learned at either a local or wider level. Learning from Deaths Policy (1 st Edition, September 2017) Page 4 of 6

Patients Requiring a Mortality Review In certain groups of patients all patients should have a mortality review: All deaths where there is a significant concern raised about quality of care (by bereaved families, carers or trust staff) All deaths in service specialties All deaths with a particular diagnosis or treatment group where a mortality alert has been raised in any way (eg SHMI/HSMR/Clinical Audit/CQC or other regulators) All deaths in low risk areas (eg elective procedures) All deaths where learning will inform the trust s existing or planned improvement work (eg if work is planned on improving sepsis care, sepsis deaths should be reviewed: these areas will be determined by the Avoidable Mortality Group) All deaths of patients with learning disabilities (the LeDeR review process must be adopted) In addition, cross-system reviews should be undertaken with collaboration from other organisations as necessary for patients dying within the trust in the following situations: All deaths occurring during pregnancy or within 6 weeks of delivery will be reviewed in collaboration with the appropriate maternity unit All deaths of neonates, infants, children and young persons up to the age of 18 years should be investigated by the Child Death Review Processes overseen by the Local Safeguarding Children s Board All deaths of patients with severe mental illness should be reviewed in partnership with the appropriate Mental Health Trust. When a death occurs in a way that involves other organisations the review must encompass all relevant episodes of care in all institutions. This includes Ambulance Trusts and other organisations as relevant. Where a death of a patient aged over 18 years could be attributable to domestic abuse/violence/neglect the safeguarding team should be contacted in order to consider a the appropriate mechanism of investigation. A further sample of deaths will be reviewed. The size and nature of this group will be determined by the Avoidable Mortality Reduction Group.This sample may be defined randomly or pragmatically; it will be varied depending upon the needs of the Trust.) Allocation and re-allocation of deaths Deaths will be identified from the patient information system (Sigma or subsequent software) and listed as a death allocated to the named consultant at the time of death. The identity of the consultant will determine the specialty within which the death occurred. The general principle to apply when considering the identity of the correct consultant and specialty is that this will usually be the team responsible for the patient at the time of their death. Occasionally it may be more appropriate for another team to be responsible for the review. An example of this situation would be when all the key management decisions and clinical care was conducted in one specialty and then the patient died shortly after transfer to another consultant/specialty. An appropriate cut off point would be that it would usually be inappropriate to review a death before they had been seen for a senior review by the new team. Where there has been an error in the recording of the consultant name and/or specialty the consultant asked to review the death should either complete the review or forward the case to the most suitable consultant as identified from the case notes during the preliminary stage of the mortality review. The consultant starting the mortality review should contact the most appropriate consultant (as identified from the case notes) and ask them to accept the patient for a mortality review under their specialty s mortality review system. Where two (or more) consultants cannot agree on which specialty should review the death they should escalate this to the Associate Medical Director for Clinical Governance to make a decision. Learning from Deaths Policy (1 st Edition, September 2017) Page 5 of 6

5.0 MONITORING OF COMPLIANCE Minimum requirement to be monitored Process for monitoring e.g. audit/ review of incidents/ performanc e manageme nt Job title of individual(s) responsible for monitoring and developing action plan Minimum frequency of monitoring Name of committee responsible for review of results and action plan Job title of individual/ committee responsible for monitoring implementation of action plan Review rates by directorate. Quarterly divisional reports to AMRG Mortality Lead Quarterly Divisional Assurance Group (DAG) and AMRG Directorate Mortality Clinical Lead (for directorates and Divisional Mortality Lead for Division. Lessons learned and action plans Reports to DAGs Mortality Lead Quarterly DAG Divisional Medical Director/DGM Delivery of actions Reports to DAGs Mortality Lead/Divisional Governance Manager (DGM) Quarterly DAG Divisional Medical Director/DGM 6.0 EQUALITY, DIVERSITY AND HUMAN RIGHT STATEMENT The Trust is committed to an environment that promotes equality and embraces diversity in its performance both as a service provider and employer. It will adhere to legal and performance requirements and will mainstream Equality, Diversity and Human Rights principles through its policies, procedures, service development and engagement processes. This policy should be implemented with due regard to this commitment. 7.0 REFERENCES National Guidance on Learning from Deaths (supplied as Appendix 1) Appendix 1 The link below allows acces to the NQB guidanceon learning from detahs in the NHS https://improvement.nhs.uk/resources/learning-deaths-nhs/ Appendix 2 The link below allows access to the Terms of Reference for the Avoidable Mortality Reduction Group I:\Mortality Reviews\Avoidable Mortality Reduction Group Terms of Reference 2017-09-26.doc Learning from Deaths Policy (1 st Edition, September 2017) Page 6 of 6