Learning from Deaths Policy This policy applies Trust wide
Document control page Name of policy Learning from Deaths Policy Names of linked Learning from Deaths Procedure procedures Accountable Medical Director Director Author with contact Interim Assistant Director of Integrated Governance details seriousincidents@nwbh.nhs.uk Status (draft/ Ratified ratified) Ratifying Audit Committee/ September 2017 Committee/ date Review date September 2020 Brief description of New policy in response to the March 2017 National changes following Guidance on Learning from Deaths issued by the review National Quality Board. Equality Impact Assessment The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others. This Policy has been Equality Impact Assessed and does not discriminate. Version control Version Development Timeline Date number 0.1 First version September 2017 0.2 Version following discussion at Patient Safety Panel September 2017 0.3 Version following further engagement and consultation September 2017 0.4 Safeguarding and Medical Director updates September 2017 V1 New policy September 2017 Page 2 of 12
Contents Page Page 1 Introduction 4 2 Purpose 4 3 Development 6 4 Definition of Key Terms 6 5 Duties 8 6 Monitoring compliance 11 7 References (legislation and guidance from other 11 organisations) 8 Associated documents 12 Appendices (If applicable) Page 3 of 12
1. Introduction The purpose of this policy is to ensure that all North West Borough s Healthcare NHS Foundation Trust (the Trust) staff understand and follow a standardised, consistent approach to learning from mortality. Most, but not all deaths, will be treated as potential Serious Incidents. This policy will guide this decision making in support of the level of investigation required. The aim of the mortality review process is to: Identify and minimise deaths due to problems in care within the entire trust Review the quality of end of life care Ensure that patients wishes have been identified and met Improve the experience of patients families and carers through better opportunities for involvement in investigations and reviews ensuring Duty of Candour. Identify and minimise avoidable admissions or late presentation Enable informed reporting with a transparent methodology Promote organisational learning and improvement Ensure all deaths are appropriately reported Deaths that are considered potential Serious Incidents will be reviewed by Case Assessment and considered at Patient Safety Panel for further investigation as described in the Trust Case Assessment Procedure. The Patient Safety Panel is a weekly meeting chaired by the Medical Director and attended by; the Chief Nurse/Executive Director of Clinical Operation, Assistant Director of Integrated Governance, Clinical Director of Operations and Integration, Deputy Director of Nursing and Quality and Assistant Clinical Directors. The Learning from all potential Serious Incident investigations will be utilised as described in the Trust Lessons Learned Procedure. This policy will complement the Lessons Learned Procedure by exploring the learning from all deaths and detailing the role of the Mortality Review Group. The Mortality Review Group is a monthly meeting chaired by the Medical Director and attended by; the Chief Nurse/Executive Director of Clinical Operation, Clinical Director of Operations and Integration, Deputy Director of Nursing and Quality, Assistant Director of Integrated Governance, the Learning Disability Network Lead and the Head of Risk and Safety. 2. Purpose This policy and procedure outline the framework for identifying, reporting, investigating and learning from deaths. The Trust will implement the requirements outlined in the Learning from Deaths framework (National Guidance on Learning from Deaths; A framework for NHS Page 4 of 12
Trusts and NHS Foundation Trusts on identifying, reporting, investigating and learning from deaths in care, March 2017) as part of the Trusts existing policies to learn and continually improve the quality of care provided to patients. Concern about patient safety and scrutiny of mortality rates has intensified recently with high-profile investigations into NHS hospital failures combined with the Dr Foster report and patient safety rating for NHS Trusts. There is an increased drive for Trust Boards to be assured that deaths are reviewed and appropriate changes made to ensure patients are safe. Effective clinical audit and peer review processes incorporating analysis of mortality contribute to improved patient safety. The Mortality Review Group meetings, established to review deaths as part of professional learning, also have the potential to help provide assurance that patients are not dying as a consequence of unsafe clinical practices. Concentrating attention on the factors that cause deaths will impact positively on all patients, reducing complications, length of stay and readmission rates through improving pathways of care, reducing variability of care delivery, and early recognition and escalation of the deteriorating patient. Retrospective case note reviews help to identify examples where processes can be improved and gain an understanding of the care delivered to those whose death is expected and inevitable to ensure they receive optimal end of life care. A formalised process will also address the Care Quality Commission s publication in December 2016 of a review into the way NHS Trusts review and investigate the deaths of patients, Learning, candour and accountability which builds on the need to maximise learning from deaths and to comply with Regulation 20 Duty of Candour. This standardised trust-wide process integrating mortality reviews into the governance framework will provide greater levels of assurance to the Trust Board and help to ensure that the organisation is using mortality rates and indicators alongside others such as incidents and complaints to monitor the quality of care and share good practice and learning from mistakes. 3. Scope This policy applies to all deaths within the following categories All deaths of an individual with a learning disability All deaths of an individual with mental health needs All deaths of 0-19 year olds All deaths in community physical health services reported in line with the Trust Incident Management (including serious incidents) policy and procedure. Page 5 of 12
All deaths where the service user family and/ or carers have raised a concern As the new mortality policy and processes matures the Mortality Review Group will decide a framework for ensuring the appropriate identification of deaths for further investigation within this category. This policy applies to all Trust employees and Non-Executive Directors. It applies to any event that affects service users, clients, children, carers, staff or visitors and any Trust property whether owned or leased, and any place where Trust staff work. This policy also applies to any contractor working on behalf of the Trust or within Trust premises. Incidents that have occurred to Trust service users or staff whilst in the course of their duties, at whatever point they are identified, must be reported in line with this policy. 4. Development This policy and associated procedure have been developed in response to the March 2017 National Guidance on Learning from Deaths which was issued by the National Quality Board. The Guidance builds upon findings from a review of 14 hospitals with the highest mortality rates and the Care Quality Commission (CQC) report; Learning, candour and accountability: A review of the way NHS trusts review and investigate the deaths of patients in England. The Guidance makes recommendations aiming to initiate a standardised approach to learning from deaths. 5. Definitions Dr. Foster Report 2011 Mortality Rate Dr Foster Intelligence is a joint venture between the Department of Health and Dr Foster Holdings LLP and their research partners at Imperial College London. It aims to improve the quality and efficiency of health and social care through better use of information. It provides comparative information on health and social care services to health professionals and organisation s to help improve the standard of healthcare. The 2011 Report highlighted trusts that had higher than expected mortality rates. The mortality rate (or death rate) is a measure of the number of deaths that occurred during a particular time period divided by the total size of the population during the same time frame. It is typically expressed in units of deaths per 1,000 individuals per year. Page 6 of 12
Mortality Avoidable/Prev entable Structured Judgment Review Expected Death Unexpected death LeDeR Regulation 20: Duty of Candour For the purpose of Mortality Meetings, mortality relates to any death of a patient that had contact with the trust within a 6 month period. These terms are used interchangeably in the NHS and for the purpose of this policy preventable or unpreventable will be used with reference to whether anything could have been done to change the outcome. More recent guidance by NHS Improvement suggests the use of the term deaths due to problems in care. The Structured judgement review blends traditional, clinical judgement based review methods with a standard format. This approach requires reviewers to make safety and quality judgements over phases of care, to make explicit written comments about care for each phase, and to score care for each phase. The result is a relatively short but rich set of information about each case in a form that can also be aggregated to produce knowledge about clinical services and systems of care. One example of this has been produced by the Royal College of Physicians Those whereby the General Practitioner/ Consultant/ Medical Officer concerned has diagnosed the patient as suffering from a terminal illness and has been seen by a registered medical practitioner within the previous 14 days and is not a case reportable to the coroner (in the community the registered medical practitioner is usually the patient s own GP) This term is specifically used when deaths occur in unexplained or suspicious circumstances. The Learning Disabilities Mortality Review Programme was set up as a result of one of the key recommendations of the Confidential Inquiry into premature deaths of people with learning disabilities (CIPOLD). CIPOLD reported that people with learning disabilities three times more likely to die from causes of death amenable to good quality healthcare than people in the general population. The LeDeR Programme (2015-2018) is run by the University of Bristol and commissioned by the Healthcare Quality Improvement Partnership (HQIP) on behalf of NHS England. A regulation within the Health and Social Care Act 2008. The intention of this regulation is to ensure that providers are open and transparent with people who use services and other 'relevant persons' (people acting lawfully on their behalf) in general in relation to care and treatment. It also sets out some specific requirements that providers must follow when things go wrong with care and treatment, including informing people about the Page 7 of 12
incident, providing reasonable support, providing truthful information and an apology when things go wrong. 6. Duties Duties set out respective responsibilities and roles of designated persons and groups with regard to management of all types and severity of incidents and respective investigation procedures. Trust Board The Trust Board has overall responsibility for effective learning from deaths within the Trust and for ensuring the Trust complies with its statutory obligations. The Trust Board should ensure that the Trust: has an existing board-level leader acting as patient safety director to take responsibility for the learning from deaths agenda and an existing nonexecutive director to take oversight of progress pays particular attention to the care of patients with a learning disability or mental health needs has a systematic approach to identifying those deaths requiring review and selecting other patients whose care they will review adopts a robust and effective methodology for case record reviews of all selected deaths (including engagement with the LeDeR programme) to identify any concerns or lapses in care likely to have contributed to, or caused, a death and possible areas for improvement, with the outcome documented ensures case record reviews and investigations are carried out to a high quality, acknowledging the primary role of system factors within or beyond the organisation rather than individual errors in the problems that generally occur ensures that mortality reporting in relation to deaths, reviews, investigations and learning is regularly provided to the board in order that the executives remain aware and non-executives can provide appropriate challenge. The reporting should be discussed at the public section of the board level with data suitably anonymised ensures that learning from reviews and investigations is acted on to sustainably change clinical and organisational practice and improve care, and reported in annual Quality Accounts shares relevant learning across the organisation and with other services where the insight gained could be useful ensures sufficient numbers of nominated staff have appropriate skills through specialist training and protected time as part of their contracted hours to review and investigate deaths offers timely, compassionate and meaningful engagement with bereaved families and carers in relation to all stages of responding to a death; acknowledges that an independent investigation (commissioned and delivered entirely separately from the organisation(s) involved in caring for the patient) may in some circumstances be warranted, for example, in cases where it will Page 8 of 12
be difficult for an organisation to conduct an objective investigation due to its size or the capacity and capability of the individuals involved; and, Works with commissioners to review and improve their respective local approaches following the death of people receiving care from their services. Commissioners should use information from providers from across all deaths, including serious incidents, mortality reviews and other monitoring, to inform their commissioning of services. This should include looking at approaches by providers to involving bereaved families and carers and using information from the actions identified following reviews and investigations to inform quality improvement and contracts etc. Medical Director The Medical Director will have overall responsibility for the learning from deaths agenda and main duties will include: Chairing the Mortality Review Group Meeting. Presenting reports to the board and ensuring that national standards are met by the trust. Ensuring that learning from mortality reviews is integral to the trusts clinical governance and quality improvement work Chief Nurse and Executive Director of Clinical Operational Services The Chief Nurse and Executive Director of Clinical Operational Services will: Be responsible at an operational level for the implementation of agreed policies and procedures on the management of mortality within the Trust, which includes Duty of Candour. Collate reports on behalf of the Mortality Review Group and share them with the Trust Board and its sub committees. Be responsible for raising risks and trends with appropriate Executives to ensure that appropriate remedial actions can be put in place. Non-Executive Directors The Non-Executive Directors will: Understand the review process ensure the processes for reviewing and learning from deaths are robust and can withstand external scrutiny. Champion quality improvement that leads to actions that improve patient safety. Assure published information that it fairly and accurately reflects the organization s approach, achievement and challenges. Mortality Review Group The Mortality Review Group will be chaired by the Medical Director, and will: Page 9 of 12
Meet on a monthly basis Receive assurance that; there are no unexplained trends in relation to deaths and the proportion of deaths being investigated is appropriate. Review thematic analysis of all incidents reported involving the death of a service user Patient Safety Panel The Patient Safety Panel will be chaired by the Medical Director, and will: Meet on a weekly basis Ensure that any actions identified in relation to mortality reviews are recorded, progressed and monitored appropriately Identify any themes and trends emanating from completed reviews. Ensure completed reviews are sent within the required timescale to the LeDeR and Public Health Drug Related Death Panel Ensure that any risks identified are considered for the Risk Register where it will be reviewed as part of the risk management process Ensure that the information and data from the above informs the mortality dashboard and feeds into the Mortality Review Group Receive assurance that; there are no unexplained trends in relation to deaths and the proportion of deaths being investigated is appropriate as required in between Mortality Review Group meetings Review thematic analysis of all incidents reported involving the death of a service user as required in between Mortality Review Group meetings. All Staff All staff are responsible for reporting an incident, and adhering to this policy and procedure when the incident falls within the scope of a mortality review. All staff are to ensure that learning from reviews and investigations is acted on to continually improve practice and improve care; contributing to a safe and high quality environment. 7. Learning and Quality Improvement The Trust will ensure that lessons learnt from mortality reviews and analysis of mortality data will result in change in organisational culture and practice by; Identifying Themes and Trends at the Patient Safety Panel and Mortality Review Group, and alerting clinical services when appropriate. Ensuring thematic Reviews are commissioned on a regular basis by the Mortality Review Group and associated action plans implemented. Ensuring action plans from Mortality Related Reviews are fully implemented. Ensuring learning is cascaded to frontline clinical staff and divisions on a regular basis by use of Patient Safety Alerts and Lessons Learned Communications Page 10 of 12
8. Monitoring of compliance with this policy Minimum requirements to be monitored All deaths reported via Datix will be presented to Patient Safety Panel with proposed actions. Surveillance of Mortality data Process for monitoring e.g. audit Quarterly reporting to Mortality Review Group Report (dashboard) detailing current mortality data according to NHS England guidance Responsible individual, group or committee Head of Risk and Safety Head of Risk and Safety Frequency of monitoring Quarterly Quarterly Responsible individual, group or committee for review of results Mortality Review Group Mortality Review Group Responsible individual, group or committee for development of action plan Head of Risk and Safety Head of Risk and Safety Responsible individual, group or committee for monitoring of action plan Mortality Review Group Mortality Review Group 9. References National Guidance on Learning from Deaths (March 2017), A Framework for NHS Trusts and Foundation Trusts on Identifying, Reporting, Investigating and Learning from Deaths in Care. National Quality Board NHS England (2015). Serious Incident Framework Supporting learning to prevent recurrence. NHS England Patient Safety Domain Care Quality Commission (2016) Learning, candour and accountability: A review of the way NHS Trusts review and investigate deaths of patients in England. CQC Mazars (2015) Independent Review of Deaths of People with a Learning Disability or Mental Health problem in contact with Southern Health NHS Foundation Trust April 2011 to March 2015. Mazars Page 11 of 12
Independent Review of Deaths of People with a Learning Disability or Mental Health Problem within Southern Health NHS Foundation Trust - Mazars December 2016. National Mortality Case Record Review Programme Royal College of Physicians 2016. Valuing People: A New Strategy for Learning Disability for the 21st Century, Department of Health, 2001. LeDeR briefing paper 10. Associated Documents This policy must be read in conjunction with other policies and guidance which impact this area. Also guidance and supporting documents can be located in the forms section of the relevant policy page. Including: Complaints and Concerns Policy and Procedure Risk Management Policy Claims Management Policy and Procedure Being Open (including Duty of Candour) Policy and Procedure Raising a Concern Policy Duty of Candour Strategy Safeguarding Children and Young People Policy Safeguarding Adults Policy Records Keeping Policy Incident Management Policy (including Serious Incidents) Service User / Family Liaison Support Procedure Inquest Procedure Page 12 of 12