Learning from Deaths Policy: The right thing to do

Learning from Deaths Policy: The right thing to do DOCUMENT CONTROL: Version: 1 Ratified by: Board of Directors Date ratified: 28 September 2017 Name of originator/author: Executive Medical Director Name of responsible Executive Medical Director committee/individual: Date issued: 28 September 2017 Review date: 27 September 2018 Target Audience Clinical staff in all services across the Trust

Sec tion CONTENTS 1. INTRODUCTION 3 2. PURPOSE 4 2.1 Definitions/Explanation of Terms Used 5 3. SCOPE 6 4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES 7 5. PROCEDURE/IMPLEMENTATION 9 5.1 Responding to and Learning from Deaths 9 5.2 Encouraging a learning from deaths culture 9 5.3 Family engagement 10 5.4 How to engage meaningfully and compassionately with bereaved families and carers 11 5.5 Patients right to confidentiality following death 12 5.6 Specific Guidance for the Hospice 13 5.7 Where the patient is under the age of 18 13 5.8 Reporting Deaths 13 5.9 IR1 Review 14 5.10 Governance process 16 6. TRAINING IMPLICATIONS 16 7 MONITORING ARRANGEMENTS 16 8. EQUALITY IMPACT ASSESSMENT SCREENING 17 8.1 Privacy, Dignity and Respect 17 8.2 Mental Capacity Act 17 9. LINKS TO ANY ASSOCIATED DOCUMENTS 18 10 APPENDICES 18 Page No Page 2 of 18

1. INTRODUCTION The death of Connor Sparrowhawk in 2013 resulted in the Mazars Report of December 2015 into deaths 2011-2015 in the Southern Health NHS Trust. The report uncovered serious concerns regarding mortality systems management The Care Quality Commission (CQC) report Learning, Candour and Accountability. A review of the way NHS Trusts review and investigate deaths of patients in England 2016. It showed that in some organisations, learning from deaths was not being given sufficient priority and that valuable opportunities for improvements were missed. A Trust response to this paper was authored by the Medical Director in January 2017. The National Quality Board National Guidance on Learning from Deaths was published in March 2017. This is the starting point to initiate a standardised approach across the NHS in the way NHS Trusts report, investigate and learn from patient deaths, which should lead to better quality investigations and more embedded learning. Alongside the development of this policy, debates have been taking place at a regional and local level in order to determine which deaths to review and how and who will carry out the reviews. These reviews should provide the Trust with valuable information in deciding how avoidable a patient death may have been and enable a Board of Directors and Executive Directors to gain assurance regarding mortality surveillance and learning. The Trust is a member of the Northern Alliance, a group of mental health trusts (some with community services) covering the area from South Yorkshire up to the border of Scotland. The Alliance shares good practice, documentation and benchmarks quality standards in relation to mortality management. The Rotherham Doncaster and South Humber NHS Foundation (RDaSH) Trust fully supports the approach to learning from deaths. This policy sets out how the Trust has responded to, and will continue to respond to, the challenge of learning from patient deaths. In addition we will make it a priority to work more closely with the families and carers of patients who have died and to ensure meaningful support and engagement with them at all stages, from the notification of the death of their loved one, involvement in the investigation process through to actions taken following on from an investigation. Page 3 of 18

1.1 Why we need this policy This policy sets out how RDaSH responds to and learns from patient deaths and the steps we take to prioritise collaborative working with families and carers working more closely with family/cares of patients who have died to ensure meaningful support and engagement at all stages of the review process. In line with the National Quality Board Guidance on Learning from Deaths 2017, every Trust must have a policy in place by Quarter 2 of the 2017-2018 year that sets out how it identifies, reports, investigates and learns from a patient s death. This would include the care leading up to the patient s death, considering if this could have been improved, including when the care had no direct link with the patient s death. This policy will inform the organisation of the staff roles and responsibilities relating to learning from deaths where a review shows the patient may have experienced poor care provision, including poor leadership and system-wide failures. Also where family/carers have raised concerns about the care provided or would like to ask questions about the patient s care and death, to promote a culture of learning lessons. Learning from a review about the care provided to patients who die in our care is integral to the Trust s governance and quality improvement work. This policy as well as informing staff of their role in relation to learning from deaths lays out what is expected of them when a patient dies and how we should engage with bereaved families and carers, to ensure there are easy opportunities for them to discuss, or ask questions about, the care received by their loved one. Where a concern is expressed staff will actively seek to provide information in an open and honest way, identifying where lessons could be learned. This process should be led by the family/carers if this is what they want, making sure they are offered contact on multiple occasions. This takes into account where family/carers have stipulated that they do not want us to contact them. 2. PURPOSE The purpose of this policy is to set out the Trust s expectation on how it processes, responds to and learns from deaths of patients where we are the main provider of care to that person. When mistakes happen, we need to do more to understand the possible causes and ensure we work with our partners on this. Staff need to understand that the purpose of reviews and investigations into patient deaths is to identify problems in care that might have contributed to the end outcome, and are key to learning lessons in order to prevent a similar event happening again. The governance process will ensure a review of the death and that there is maximum learning from deaths using evidence based methodology for each review. This takes into the account the North East and Cumbria Learning Disability Network Programme to conduct reviews of people with a Learning Disability (part of the LeDeR process- Learning Disabilities Mortality Review). Page 4 of 18

While a focus on process is important, everything that is done should focus on the outcomes from the learning from deaths. With this in mind the core objectives of this policy are to ensure that the Trust: Prioritises and enables meaningful engagement and compassionate support between families/carers and staff that is open and transparent at whatever stage the engagement takes place to raise questions or share concerns about the care provided at every stage from notification of death to the review report, the lessons learned and action taken Identifies what can be improved upon in terms of service provision and ultimately reducing death rates and helping to ensure parity of esteem across the range of the health and social care system Maintains a standardised approach to learning from deaths across the Northern Alliance supporting shared definitions, approaches to continuous improvement, sharing data and agreeing approaches for evaluation. Providing learning at a personal and team level and for the wider care system Ensuring the focus goes across the care system to: o Engage with other stakeholders (acute Trusts. Primary care, public health, safeguarding, Health and Wellbeing Boards etc.) in systems for learning using shared values o Gaining commitment of other stakeholders to assure a genuine focus on what could/can be changed o Promote access to and sharing of broader data/information including clinical case reviews from other providers, information systems, epidemiological information and the sharing of expertise To evaluate the Trust s learning from deaths in line with the Northern Alliance of mental health trusts agreed processes. 2.1 Definitions/Explanation of Terms Used As the Trust provides a wide range of clinical services across inpatient, community and other provider organisations it can lead to a degree of confusion as to who is responsible for the reporting and investigating of a patient s death, and leave the risk of a death being double reported and investigated. To support staff in their decision making the Trust only requires staff to report and investigate a death were we are the main provider of care as defined below. However if there is any doubt staff are to contact their line manager for advice. 2.1 A We are the main provider if at the time of death the patient was subject to: An episode of inpatient care within our service. An episode of community treatment under CPA. An episode of community treatment due to identified mental health, learning disability or substance misuse needs. A Community Treatment order. A conditional discharge. Guardianship. An inpatient episode or community treatment package within the 6 months prior to their death (Mental Health services only). Page 5 of 18

2.1 B Patients who meet the above criteria but are inpatients within another health care provider or custodial establishment at the time of their death: In these circumstances the death will be reported by the organisation under whose direct care the patient was at the time of their death. That organisation will also exercise the responsibilities under duty of candour. However there will be a discussion to agree if it is to be a joint or single agency investigation (this will be determined by the cause of death) and in the case of joint investigations who the lead organisation will be. 2.1 C Services provided by the Trust where we are not classed as the main provider For the following services the Trust is only providing a small component of an overarching package of care and the main provider is the GP or other healthcare organisation. Tissue viability Dietetics District Nursing The drug and alcohol shared care services Care home liaison Acute hospital liaison Community physiotherapy Macmillan Nurses (now referred to as the Specialist Palliative Care team) Health Visitors Podiatry 2.1 D Exceptions In addition to the above if any act or omission on the part of a member of Trust staff from one of the services where we are not classed as the main provider is felt to have in any way contributed to the death of a patient, an investigation will be undertaken by the Trust. Also there may be deaths which do not meet any of the above criteria but require investigation due to clinical complexity or other reason. 3. SCOPE This policy applies to all Trust staff involved in caring for patients, or have responsibility for the quality of patient care, to feel more confident in answering questions and reviewing deaths to identify how we can learn from them and improve care provided. The National Quality Board Guidance on Learning from Patient Deaths applies to all acute, mental health/learning disability and community NHS Foundation Trusts. Page 6 of 18

4. RESPONSIBILITIES, ACCOUNTABILITIES AND DUTIES Mortality Governance is now a priority for Trust Boards and the March 2017 Learning from Deaths Framework places great emphasis on the importance of Board Leadership to ensure that learning from patient deaths becomes embedded in the organisation. Within the Trust the following responsibilities, accountabilities and duties apply in relation to this policy. 4.1 Chief Executive, Executive Trust Board Directors and Non-Executive Directors Trust Boards are accountable for ensuring compliance with the National Guidance on Learning from Deaths, alongside NHS England s Serious Incident Framework 2015 and working towards achieving the highest standards in mortality governance. They are also responsible for ensuring quality improvement remains key by championing and supporting learning that leads to meaningful and effective actions that improve patient safety and experience, and supports cultural change. The Trust Board is required to identify an existing Executive Director to be the Patient Safety Director with responsibility for the learning from deaths. Within RDaSH this is the Executive Medical Director. Additionally a Non-Executive Director is nominated to take responsibility for oversight of progress and act as a critical friend holding the organisation to account for its approach in learning from deaths. Both the Executive and Non-Executive Director leads will have the capability and capacity to understand the issues affecting mortality in this Trust. They will challenge where necessary, to ensure high standards in mortality governance are maintained and that the care provided to patients who die is integral to the Trust s governance and quality improvement work. In addition to the above the Non Executive Directors are responsible for: Ensuring that the processes in place focus on learning and can withstand external scrutiny, by providing challenge and support. Holding the organisation to account for its approach and attitude to patient safety and that there is evident learning from all deaths. 4.2 Mortality Surveillance Group The Mortality Surveillance Group was formed in 2016 and meets on a monthly basis and is responsible for : Having oversight of the review of deaths within the Trust including all expected / unexpected deaths, of patients currently in Trust care (and in addition within a 6 month period of discharge following mental health or LD care). Reviewing mortality data for patients and service users Using mortality data to identify key risk groups or situations for suicide with the aim of targeting those groups or situations more effectively and thus reducing suicide rates. Overseeing the Trust work to reduce deaths in physical health patients contributed to by mental health difficulties by improved mental health screening in patients with Page 7 of 18

long term conditions. Reviewing community hospital deaths in order to reduce rates of avoidable deaths. Benchmarking Trust data with other organisations. Engaging with relevant external regional and national bodies contributing to the management and improvement of quality learning in relation to mortality management. Acting as the organisation s expert advisory group in terms of scanning for and digesting national guidance and other relevant documentation. 4.3 Care Group Directors, Associate Nurse Directors, Associate Medical Directors/ Lead Consultants, Medical Staff, Service Managers, Modern Matrons, Ward and Team Managers, all Registered Nurses and Allied Healthcare Professionals It is the responsibility of the above staff : To foster a culture of responding to the deaths of patients who die/under our care and ensure staff reporting deaths have the skills and training to support the review process. To participate in the review and investigation of patient deaths support staff that are to review and investigate the deaths ensuring they have the time to carry this process out in skilled way to a high standard, and as part of that to. Ensure staff have the right level of skill through training To promote learning from deaths through facilitating and giving focus to the review, investigation and reporting of deaths. To ensure that all learning from the process of review and investigation is shared and learning is acted upon. All Healthcare professionals need to acquaint themselves with this policy and understand the process for learning from deaths 4.4 Head of Patient Safety The Head of Patient Safety is responsible for ensuring that : Data is collected and published to monitor trends in deaths from April 2017 onwards, with Board level oversight of this process. Ensuring the Safeguard reporting system is used to its full potential to record deaths and the circumstances of individual deaths nformation is processed consistently, precisely and in a meaningful way to fulfil the governance processes required to ensure high standards in mortality governance are maintained. The Trust requires all staff to be open, honest and transparent about reporting deaths and for engaging with families and cares of the deceased to be their priority. Enabling them to ask questions about care and identify if care can be improved. Page 8 of 18

5. PROCEDURE/IMPLEMENTATION 5.1 Responding to and Learning from Deaths We know our staff work under increasing pressures to deliver safe, high quality care and that sometimes patients experience a poor quality service that is rarely due to an individual. The culture change is about supporting staff to be confident in identifying what they can do better, which may inform the Board on what resources and investment maybe needed. 5.2 Encouraging a learning from deaths culture The main way in which the organisation learns from the deaths of patients in their care is through having a robust review process in place and ensuring that any emerging themes/trends are analysed, actioned and shared with the clinical staff delivering care. There is a governance structure in place to facilitate this (which can be seen in Section 5.8 of this policy) and the Mortality Surveillance Group is responsible for providing the required oversight within the Trust. This group meets on a monthly basis and receives local data reports which are used to identify emerging themes and track trends over time. This data and analysis is presented to the Care Groups on a quarterly basis within the Patient Safety Dashboards. The group also considers the implications of any National trends and guidance on Trust practice, and is an active member of the Northern Alliance. When any emerging themes are identified consideration is given to the need to review staff training to ensure we have a competent and responsive clinical workforce. This is done in conjunction with the Deputy Director of Organisational Learning. The Mortality Surveillance Group will also provide the mortality data which the Trust is required to publish on a quarterly basis via the Board of Directors public session/ minutes. This data is required to include the: total number of deaths of people under the care of the Trust during the quarter (with deaths of patients with learning disability specifically highlighted as per the LeDeR process) total number of deaths that were subject to a structured review (with deaths of patients with learning disability specifically highlighted as per the LeDeR review process) total number of deaths that were subject to a serious incident investigation total number of deaths thought (more than 50% likely) to have occurred as a result of a problem with care delivery (with deaths of patients with learning disability specifically highlighted from the LeDeR process) themes and issues identified through structured review / serious incident investigation actions taken as a result and progress of action implementation. In addition one of the Trust s Sign up to Safety pledges is to reduce to 0% all avoidable suicides,and there is a programme of work in place to support the achievement of this target which is underpinned by each locality s public health suicide prevention strategy. For every death that is subject to a serious incident investigation clinical staff involved in the patient s care receive direct feedback on the investigation findings and recommendations from the lead investigator. Page 9 of 18

5.3 Family engagement For the death of any patient in receipt of services from the Trust staff must comply with the Being Open process, and as a minimum are to undertake the actions as detailed below in sections 5.3.1 and 5.3.2. For more detailed guidance staff should refer to the Trust s Being Open and Duty of Candour Policy. 5.3.1 Inpatient Services For all deaths within inpatient services the family/carer will be contacted at the point the patient has died by a staff member who knew the patient to inform them of the death. Condolences are to be offered and where the death is to be reviewed the family/ carer is to be given the opportunity to be involved in the review of their loved ones care leading up to when they died. If appropriate their preferred method of future contact re the investigation is to be established. It is understood that this is a sensitive situation and that families/carers may respond differently to the death and the information offered at that initial point. Staff may need to offer the opportunity for involvement in a follow up call. However, if the family/carer say they want to be involved, staff will treat the family/carer as an equal in the process from the beginning; including making the decision as to whether there is a structured case review and then they should be supported to be involved at any stage they consider is right for them. If the family/carer decides they do not want to be involved in the review process we will make it clear they can contact us at any time should their decision change; we will also offer to forward to them the summary of any findings. If the family does not want contact at all about the process or findings, this will be honoured and recorded on the investigation system. 5.3.2 Community Services Within the community services it is likely that notification of the patient s death will either come direct from the patient s relative/carer or another agency such as the Police or HM Coroner s office. If the notification comes via another agency the care coordinator or another staff member who knew the patient should make contact with their relative/carer and follow the advice as above. In the event that the service is notified of the death by another patient steps should be taken to verify the accuracy of the information prior to a call being made to the patient s relatives/carer. 5.3.3 Duty of Candour Whilst the principles of being open are to be applied following all deaths, where the Trust is the main provider of care and treatment, if the death was as a direct result of a patient safety incident whilst the patient was in receipt of services or in the 6 months following discharge from services, Duty of Candour applies. To comply with the initial requirements under duty of candour staff must: Page 10 of 18

As soon as possible after the death provide support to the patient s family and carers. This support is to remain in place for as long as required. Have the Being Open conversation. Apologise for the death and offer condolences. Inform the family of the investigation process and expected time frames. Within 10 working days of the death write to the family. This letter will include: The information which was provided verbally. The apology that was given verbally. Any additional information which has come to light since the initial conversation took place. An outline of the investigation process. Who the investigator is and that the investigator will contact the family to discuss the remit of the investigation and ascertain if the family have any particular issues/concerns they want to be considered within the remit of the investigation. Staff are to refer to the Trust Being Open and Duty of Candour Policy for full details. 5.3.4 Providing written information to relatives/carers The death of a close family member or friend is emotionally difficult, and often people do not know what they need to do or where they can go for support. Whilst information can and should in the first instance be provided verbally, due to their level of emotional upset people may not always retain this information and in recognition of this the Trust has developed an information package for bereaved families (see Appendix A) and a copy of this should be offered. 5.4 How to engage meaningfully and compassionately with bereaved families and carers Where there is to be review of a death as previously stated, initial contact with families and carers should be managed by the clinical staff involved in the deceased s care and who have the skills to offer families and carers reasonable support. If already established families and carers are to be contacted about the review via their preferred method of contact. In cases where the preferred method of contact is not known it should in the first instance be by letter as this will allow the recipient time to consider what they wish to do. A template letter is available for staff to use in Appendix B and this is to be personalised to reflect the individual circumstances of each family. In relation to family/carers who do not acknowledge receipt of a contact letter or initially decline to be involved in a review it is recognised that sometimes newly bereaved people may not be able to make a decision at this time, so staff should offer a definite date/time when they will contact the family member/carer again to talk again about what the family member/carers want to do. Where the family/carer do wish to be involved it is to made clear to them that the purpose of the review will be for lessons to be learned and decisions made in relation to how improvements can be made to the services. The family/carer should also be asked if they have any specific questions they want answered and given the opportunity to Page 11 of 18

express concerns about the care they witnessed. For any family/carer where their first/preferred language is not English staff are to refer to and follow the Trust Interpreters Policy (The Provision of, Access to, and Use of Interpreters for Patients /Service Users and Carers. It also needs to be established as to whether or not they want to receive a written summary of the review findings, attend a follow up meeting, or both. All contact with the family member/carer must be recorded on the electronic care record and investigation data base. If a family member wants to seek independent legal advice then this should be respected and not seen as threatening in any way. It should not lead to an automatic involvement of legal representation on behalf of the Trust. If any staff member within the Trust receives a communication from a legal professional, this must be discussed with an appropriate line manager who can seek further advice from the relevant Care Group management team or from a relevant Executive Director. The Caldicott Guardian can also offer advice in relation to patient confidentiality matters. Where a family member/ carer is a patient of the service Where a family member/carer is also in receipt of services from our Trust arrangements are to be made with their care coordinator/lead clinician for them to be offered increased support. Additionally there may be circumstances where due to their level of distress they find it difficult to continue their own engagement in their treatment programme, and in these cases an offer is to made for the transfer of their care to another provider. If this offer is accepted Trust staff will make the necessary arrangements. 5.5 Patients right to confidentiality following death During conversations with bereaved families/carers there will be occasions when they ask very specific questions in relation to the care and treatment their relative was receiving. Whilst in most cases this will not pose an issue, there may be circumstances where we hold sensitive information that the patient may not have wished to be shared, or where sharing of information could negatively impact on the emotional wellbeing of the family member/carer to whom it is being disclosed. In answering such questions staff need to be mindful of the fact that current extant guidance is that confidentiality obligations owed by health professionals continue even after death. Additionally the Department of Health, General Medical Council and other clinical professional bodies have long accepted that the duty of confidentiality continues beyond death and this is reflected in their extant guidance. As each situation is unique it is not possible to provide definitive guidance to staff on what information can and cannot be shared in these circumstances. Therefore any staff member who is unsure should seek advice through the following escalation process : 1. Refer to the Trust Access to Health Records Policy. 2. Speak with their immediate line manager. 3. Contact the Trust Information Governance service for advice. Page 12 of 18

4. Contact the Trust Caldicott Guardian. Sections 5.5 to 5.9 below are included on a quick reference flow chart for staff to refer to. A copy of which is included in Appendix C. 5.6 Specific Guidance for the Hospice Due to the nature of the service provided by the Hospice (because deaths are expected) the only deaths which are reportable as an incident (via IR1) under this policy are those which meet the criteria for reporting to the Coroner (for example deaths within the first 24 hours of admission, deaths due to certain industrial diseases or unexpected deaths) However all deaths that occur in the Hospice are reviewed and this data is supplied to the Mortality Surveillance Group on a monthly basis. A summary of this data will be included in the Mortality Quarterly Report to the Board of Directors. 5.7 Where the patient is under the age of 18 In the case of any death where the patient is under the age of 18 the death will be subject to the Child Death Review process 2008. These reviews are the responsibility of the local Safeguarding Children Boards, and serve a key Public Health role by providing contemporary and comprehensive information on patterns of child death, to promote action to prevent deaths and support wider aspects of inter-agency working to safeguard children and promote child welfare. The reviews are undertaken by a group of key professionals who come together for the purpose of: Enquiring into and evaluating each unexpected death of a child. Providing an overview of all child deaths (under 18 years) in the Local Safeguarding Children's Board (LSCB) area. The death of person under the age of 18 is also reportable to the coroner. 5.8 Reporting Deaths As soon as the clinical service becomes aware of the death of a patient for whom we are the main provider of care an IR1 is to be completed (see separate process for reporting deaths in the Hospice). In addition if the death is due to unnatural causes such as suicide, or as a result of some other serious incident, the relevant line manager, or manager on call (if outside normal working hours) is to be notified and a STEIS completed and submitted within 24 hours of the service becoming aware of the death. Staff should refer to the Trust Serious Incident Policy for full guidance. Deaths within the Learning Disability Services In the case of a death within the Learning Disability services a report also has to be made to the Learning Disabilities Mortality Review (LeDeR) Programme. Page 13 of 18

The death is to be notified by the ward /service manager to the following single point of contact. Either via the confidential phone line 0300 7774774, or on the secure website: http://www.bristol.ac.uk/sps/leder/notify-a-death/ The person reporting the death will be expected to complete as much of the death notification information as possible. The core data will then be checked by the LeDeR Team to ensure the death meets the inclusion criteria for review by the Programme; i.e. that the person is aged between 4-74 years, has learning disabilities and is registered with a GP in England. Once confirmed, the person s death will be allocated a Programme ID number and reported to the LeDeR Local Area Contact who will be responsible for arranging the necessary review. Deaths which are reportable to the Coroner Any death which meets the following criteria is reportable to the Coroner: 5.9 IR1 Review Suspected suicide of an inpatient. Suspected suicide of a person within 6 months of discharge from service. Death of a patient who is subject to detention under the Mental Health Act 1983, including patients subject to a Community Treatment Order. Death of a patient under the age of 18. If the death is as a result of an occupational injury / disease. Homicide. Where the death is unexplained. Where the Death was expected and due to natural causes In these cases the IR1 is to be reviewed by the Band 7 ward/service manager who will be responsible for determining if the care provided was suitable and sufficient. This review is to take place as soon as is practicably possible following the death, and no later than 48 hours. It is the responsibility of the Care Group Triumvirate to ensure that this is allocated to another manager of an equivalent grade and clinical speciality to provide the necessary cover in the event that the ward/service manager is off work for any reason. Within the Trust all reported incidents which are rated as moderate or above are automatically sent to members of the Care Group Triumvirate who are also responsible for completing a peer review of the information provided on the incident report and seeking additional information if they feel it is needed. If both the ward/service manager and Associate Nurse Director are satisfied that there are no areas of concern in relation to the patient s death the ward/service manager can close the IR1 down on the system. Page 14 of 18

If any concerns are identified the ward /service manager is to record that a structured review is to be undertaken and then close down the IR1. The ward /service manager is to then complete an incident appraisal form (Appendix D) and forward to the Care Group Triumvirate for a structured review to be undertaken. Where the death was unexpected but due to natural causes The definition for this category of death is that whilst the patient was known to have a life limiting illness the actual death was sooner than had been expected. In these cases the IR1 is to be closed by the ward/service manager, and in the manager s action it is to be recorded that a structured review is to be undertaken. The ward /service manager is to complete an incident appraisal form (Appendix D) and forward to the Care Group Triumvirate for a structured review to be undertaken. Where the death was unexpected or meets the criteria for referral to the Coroner In these cases the IR1 is to be closed by the ward/service manager, and in the manager s action it is to be recorded that a Serious Incident Review is to be undertaken and the STEIS number included in the narrative to enable tracking of the subsequent serious incident investigation. If the death has been reported to the Coroner this is to also be recorded in the managers action section of the IR1. NB. Where a family member/ carer or staff member have raised significant concerns about the death a structured review should always be undertaken. Structured Reviews. To ensure objectivity the structured review will be undertaken by the Care Group Triumvirate as they will not have been directly involved in the care of the patient. Where possible the structured review should be completed within 5 working days of the patient death. Outcomes from structured review If the incident does not meet the criteria for a serious incident investigation the Care Group Director is to arrange for a clinician who was not involved in the patient s care or a member of the Care Group Triumvirate to undertake a concise Root Cause Analysis. This is to be completed within 4 weeks of the death and the completed form submitted to the Trust patient safety team. The findings will be included in the data report to the Mortality Surveillance Group and a copy of completed RCA form attached to the IR1. In the event that whilst undertaking the RCA additional information comes to light which indicates the criteria for a serious incident investigation are met the Care Group Director is to be informed and they will complete a STEIS and submit it to the Trust patient safety team. The investigation will then follow the serious incident process and time frames. If it is concluded that a full serious incident investigation needs to be undertaken a Page 15 of 18

STEIS is to be immediately completed and submitted to the Trust patient safety team. The investigation will then follow the serious incident process and timeframes. 5.10 Governance process The following Governance framework is in place to oversee how the Trust reviews and learns from patient deaths. Board of Directors Executive Management Team Quality Committee (for assurance) Operational Management Quality Meeting Mortality Surveillance Group Care Group Quality meetings Doncaster Rotherham North Lincolnshire Children s 6. TRAINING IMPLICATIONS There are no specific training needs in relation to this policy, but all clinical staff will need to be familiar with its contents. Staff will be made aware through: Team Brief Team meetings Local Induction Supervision 7. MONITORING ARRANGEMENTS There are no additional monitoring needs in relation to this policy as all monitoring and reporting is undertaken via the Mortality Surveillance group. Page 16 of 18

8. EQUALITY IMPACT ASSESSMENT SCREENING The completed Equality Impact Assessment for this Policy has been published on the Equality and Diversity webpage of the RDaSH website click here 8.1 Privacy, Dignity and Respect The NHS Constitution states that all patients should feel that their privacy and dignity are respected while they are in hospital. High Quality Care for All (2008), Lord Darzi s review of the NHS, identifies the need to organise care around the individual, not just clinically but in terms of dignity and respect. Indicate how this will be met All identified issues in relation to the impact of this policy on the privacy; dignity and respect of patients have been addressed within the policy. As a consequence the Trust is required to articulate its intent to deliver care with privacy and dignity that treats all service users with respect. Therefore, all procedural documents will be considered, if relevant, to reflect the requirement to treat everyone with privacy, dignity and respect, (when appropriate this should also include how same sex accommodation is provided). 8.2 Mental Capacity Act Central to any aspect of care delivered to adults and young people aged 16 years or over will be the consideration of the individuals capacity to participate in the decision making process. Consequently, no intervention should be carried out without either the individuals informed consent, or the powers included in a legal framework, or by order of the Court Indicate How This Will Be Achieved All individuals involved in the implementation of this policy should do so in accordance with the Guiding Principles of the Mental Capacity Act 2005. (Section 1) Therefore, the Trust is required to make sure that all staff working with individuals who use our service are familiar with the provisions within the Mental Capacity Act. For this reason all procedural documents will be considered, if relevant to reflect the provisions of the Mental Capacity Act 2005 to ensure that the interests of an individual whose capacity is in question can continue to make as many decisions for themselves as possible. Page 17 of 18

9. LINKS TO ANY ASSOCIATED DOCUMENTS Being Open and Duty of Candour Policy. - Corporate Polices, Patient Safety Section. Interpreters Policy (The Provision of, Access to and Use of Interpreters for Patients /Service Users and Carers).- Clinical Policies, Admission and Access to Services section. Incident Reporting Policy. - Corporate Polices, Patient Safety Section. Serious Incident Policy. - Corporate Polices, Patient Safety Section. NATIONAL QUALITY BOARD (2017).National Guidance on Learning from Deaths: A Framework for NHS Trusts and Foundation Trusts on identifying, Reporting,Investigating and Learning from Deaths in Care. NHS IMPROVEMENT. National Guidance on Learning from Death: Information and resources for trust boards. Available on line at www.ahsa-nenc.org.uk 10. APPENDICES Appendix A Support for Families and Carers following a Sudden Death Appendix B Letter Template for Families and Carers Appendix C Mortality Reporting and Review Process Appendix D Incident Appraisal Form Page 18 of 18

APPENDIX A SUPPORT FOR FAMILIES AND CARERS FOLLOWING A SUDDEN DEATH 1

When someone close to you has died unexpectedly, you will probably experience a range of emotions and physical sensations. As well as shock and numbness, this can include sadness, anger, guilt, relief, despair and fear. When death comes out of the blue, there is no chance to prepare oneself, no chance to say good-bye, no chance to make amends for all the quarrels, for things that were said and done that now cannot be undone, or unsaid. Suicide is a particularly difficult form of death for a surviving family and friends with many unanswered questions, could their lives have been so full of despair that they felt that death was preferable to life and the biggest question asked by many bereaved families is why? Many people bereaved by suicide eventually come to accept that they will never really know the reason why the person did what they did. This booklet is written to help you better understand and cope with the experience of traumatic grief; the grief people are faced with after a sudden unexpected traumatic death. It provides information on support agencies and resources that may be of help to you. Further Information about Coroners and Inquests can be obtained from the Coroners Offices This booklet has been produced to complement the NHS booklet Help is at Hand which is a detailed and very 2

helpful resource for people bereaved by sudden traumatic death.. Please see the last page of the leaflet for details of how to get a copy THE FIRST FEW WEEKS The first weeks and months after a death are often the worst. Emotions and grief can present at any time triggered by people, places, something heard on the TV or radio, or by your own memories. At these times having someone with whom you can cry, someone to whom you can talk to can be a great source of comfort and support. If you follow a religious faith, this may be a vicar, pastor or with a fellow member of your faith. SHOCK AND NUMBNESS Shock is common during the days and weeks following a death. What has happened may seem unreal and you may feel numb, almost without feelings. You may find it difficult to take in what has happened. You may find it difficult to accept that your loved one has died and is not going to be around anymore. You will need time to deal with this and help from family and friends can be invaluable Confusion, panic and fear are common reactions. You may feel restlessness, tired, difficulty concentrating or remembering things, difficulty sleeping, loss of appetite, nausea, and for women, normal menstruation cycle may be disturbed.. As our body and our brain struggle to make sense of what has happened, our feelings can undergo massive shifts from tears to anger, disbelief to fear. Being able to talk, to share these experiences, to feel listened to is important. 3

LONGING AND QUESTIONS You may feel overwhelmed and think you ll never be able to cope. Don t expect too much of yourself. Try not to think too far into the future, but concentrate on getting through day to day. You may experience feelings of longing to touch, talk or be with that person. These can be powerful feelings at times. You may find that you have to talk about things repeatedly with friends and family. Over and over you may replay the events leading up to or after the death, going over what has happened, trying to organise and make sense of what has happened, or asking yourself why, why? You may find yourself wondering could something have been done to stop it, could I have done something different, or thinking 'if only' we/i could have done something different. Some people may feel personal responsibility, especially if confronted with the death of a child, and blame themselves As well as the usual feelings of bereavement, you may have a number of conflicting emotions. You may feel: 4 Angry with the person for taking their own life. Rejected by what they have done. Confused as to why they did it. Guilty - most people take their own life as an act of desperation. How could you not have noticed how they were feeling? Guilty for not having been able to stop their death. You may go over in your mind the times

5 you spent with them and ask yourself if you could have prevented it, about whether they suffered. Ashamed by what they did - particularly if your culture or religion sees suicide as sinful or disgraceful. Reluctant to talk to other people about it GUILT AND ANGER You may feel upset and angry at the injustice or the senselessness of the person's death. These may be directed at the person, the authorities, family or at oneself. Although understandable such feelings can spill out and interfere with your life and your relationships with others Feelings of anger toward the person who has died are particularly distressing and confusing. This may arise from a sense of abandonment, of being left behind. Or your feelings may be stronger, of rage, rage at the person and rage at what has happened and the sheer senselessness of death. You may be angry and want to blame other people doctors, health or social care workers; you may feel they did not do enough or did not care properly for your loved one. It may help you to remember that the changes in behaviour that lead to suicide can be very gradual. It is very difficult to see when a person gets to the point where they want to take their own life, and even mental health professionals find it hard to know when a person is particularly at risk. Once a person has decided to take their life, they can go to great lengths to cover up their plans. Try to remember that you could not predict the future and that nobody is responsible for the actions of

another person. No one is perfect, and the reasons for suicide are seldom simple. Try to forgive yourself if there are things you said or did which you now regret. SLEEP PROBLEMS Some sleep disturbance is normal following a sudden death. It is normal to be uneasy in the first few weeks. To help. Prepare yourself for sleep; avoid coffee or alcohol before bed; leave a gap of three or four hours between your last meal and going to bed. Try to unwind drinking warm milk, having a relaxing bath or shower; reading or listening to music before you settle down to sleep. Try and distract yourself from thoughts and worries by reading a book, planning the next day, Keep a -pad by your bed. If there is some problem or some thought that is keeping you awake, make a note of it to deal with it during the next day. PROBLEMS WITH YOUR APPETITE Grief can take away people's appetite. You may have no appetite but by neglecting your diet, you risk neglecting yourself making it even harder to cope with things. Try having smaller and more frequent snacks rather than large meals. Choose snacks that are rich in energy and nutrients such as nuts, dried fruit, milk, cereal bars or fruit scones. Choosing some of your usual favourite foods may help make food seem more appealing. If it's hard to motivate yourself to cook, get in some ready meals and try to eat one every day at your normal 6

mealtime. If you can't face a cooked meal try a sandwich instead. It's OK to stick to simple things like cereal or toast but eat some fruit or fruit juice as well to make sure you get your vitamins and minerals. HELP FROM FAMILY AND FRIENDS Can provide help and support, knowing that someone is there, care and support when words are not enough. To be able to talk about feelings of pain and distress if you feel the need to, to be able to cry and feel supported. Practical help with cleaning, shopping or looking after children can ease the burden of being alone. Elderly bereaved partners may need help with the chores that the deceased partner used to handle - coping with bills, cooking, housework, getting the car serviced etc. It is important to allow enough time to grieve. Some can seem to get over the loss quickly, but others take longer. So don't expect too much too soon you need the time to grieve properly HELP FROM YOUR DOCTOR See your doctor if you find that you are having frequent nights where you cannot sleep. 7

Help can be arranged through your GP for counselling If depression continues to deepen, affecting appetite, energy and sleep you should see your GP. Bereavement turns our world upside-down and is one of the most painful experiences we endure. It can be strange, terrible and overwhelming. In spite of this, it is a part of life that we all go through and usually does not require medical attention. THE DEPARTMENT OF HEALTH'S SUICIDE BEREAVEMENT GUIDE HELP IS AT HAND advises the following suggestions may help you cope if you've lost a loved one through suicide. Set aside some time each day for grieving so that you can cry, remember the dead person, pray or meditate. Record your feelings, thoughts and memories in a journal. Writing may help you gain some control over intense emotions and so reduce their power. Take care of yourself. When you are able, set aside time for things that you used to enjoy. This is not disloyal and will help you cope with your grief. Exercise should help you feel better emotionally and will make you physically tired so that you sleep better. 8

Meditation, relaxation techniques, massage and listening to music can help reduce the emotional and physical stress of bereavement. Some people find it helps to express their feelings through writing poetry or painting. Other creative activities can also be healing and restorative. Avoid making major decisions, like disposing of the person s belongings, soon after the death. You may not be thinking clearly and may do things you later regret. Birthdays and the anniversary of the death can be difficult. Talk to other family members and plan in advance how you want to spend the day. You may feel particularly down when the tasks of planning the funeral and sorting out the affairs of the person who died are over. Ask for help if you need it. Alcohol or drugs may provide short-term relief from painful feelings, but they delay grieving and can cause depression and poor health. If you are feeling depressed (which may affect your sleep, appetite and lead to suicidal thoughts), get help from your GP. You may prefer to seek support from people other than friends or family. Help is available from bereavement groups, self-help groups, faith groups and through bereavement counseling INQUESTS AND INVESTIGATIONS In England and Wales, all unexpected deaths (such as possible suicides, accidents or homicides) must be 9

investigated. The death will be reported to the local coroner, who will usually hold an inquest WHAT DOES THE CORONER DO? A coroner is an independent judicial officer. A coroner must be a lawyer or a doctor, and in some cases is both WHAT IS A CORONER S OFFICER? Coroners Officers, who may be police officers, work under the direction of coroners and liaise with bereaved families, police, doctors and funeral directors. WHAT IS AN INQUEST? An inquest is a public, legal inquiry to find out the facts about the death and deliver a verdict on the cause of death. It is not a trial and is not intended to blame anyone. It looks to answer the following: Most inquests are heard by the coroner sitting alone without a jury but there are some circumstances where a jury will be called. The purpose of an inquest is to answer 4 questions 1 Who the deceased was 2 When he/she died 3 Where he /she died 4 How he /she died The coroner may open an inquest within a few days of the death. This usually involves a short hearing and 10

formal identification of the person. The inquest is then adjourned until all the necessary information is gathered. At the full inquest, the coroner will call witnesses such as police, other relevant people (for example the pathologist who carried out the post-mortem), doctors, family members and other witnesses, to give evidence. Statements given to the police, including what relatives have told them, may be read out. The coroner will determine which witnesses to call. WHO ATTENDS THE INQUEST? Any member of the public can attend an inquest. Close relatives will be given details of the time and place of the inquest in advance. The press may be present. Further information regarding Inquests can be obtained from the Coroner s office FURTHER INFORMATION FOR SUPPORT AND HELP Help is at Hand - Department of Health A resource for people bereaved by suicide and other sudden, traumatic death http://www.nmhdu.org.uk/silo/files/help-is-at-hand.pdf LOCAL 11

Cruse Help for anyone bereaved by death to understand their grief and cope with their loss. National Office 0208 939 9530 Helpline 0844 477 9400 Young People's Helpline 0808 808 1677 www.crusebereavementcare.org.uk Rotherham 01709 564205 Doncaster 01302 814647 Scunthorpe 01724 281178 Grimsby 01472 814455 ( grimsby@cruse.org.uk) Bereavement Services Rotherham Bereavement Services Ridgeway East Herringthorpe Rotherham S65 3NN Telephone No: (01709) 850344 Doncaster Bereavement Services Rose Hill Cantley Lane Cantley Doncaster DN4 6NE 01302 535191 cems@doncaster.gov.uk Bereavement Services Office Woodlands Crematorium Brumby Wood Lane 12

Scunthorpe North Lincolnshire DN17 1SP Tel: 01724 747555 Email: crematorium@northlincs.gov.uk Register Offices Doncaster The Registrar s Office, Elmfield Park, South Parade, Doncaster DN1 2EB Telephone: (01302) 364922 Rotherham Riverside House Rotherham Tel: 01709 823542/ 01709 382121 North Lincolnshire 92 Oswald Road Scunthorpe North Lincolnshire DN15 7PA 01724 842425 registrars@northlincs.gov.uk. Coroners North East Lincolnshire : Civic Offices Knoll Street Cleethorpes DN35 8LN. Telephone: 01472 324020 13

Rotherham and Doncaster H M Coroners Court and Office College Road Doncaster 01302 320844, 343864, 738843 hmc.doncaster@doncaster.gov.uk Manchester City District, HM Coroner's Office, The Manchester Magistrates and Coroner's Court, Crown Square, Manchester, M60 1PR Tel: 0161 830 4222 Email: coroners@manchester.gov.uk NATIONAL Survivors of Bereavement by Suicide www.uk-sobs.org.uk National Helpline - 9am to 9pm every day - 0844 561 6855 (open daily 9.00 am to 9.00 pm) Tel:0115 944 1117 (office) Email:sobs.admin@care4free.netWebsite:www.uksobs.org.uk. Offers group meetings, telephone support and information to meet the needs and break the isolation of people bereaved by suicide. Asian Family Counselling Service Tel: 020 8571 3933 Muslim Women s Helpline Tel: 020 8904 8193 or 020 8908 6715 (both open Monday to Friday, 10.00 am to 4.00 pm) Confidential listening service, referral to Islamic consultants and practical help and information. 14

Jewish Bereavement Counselling Service(London based)tel:020 8457 9710 Email:jbcs@jvisit.org.uk Website:www.jvisit.org.uk/jbcs The Bereavement Trust A listening ear, information and support in time of sorrow General Helpline: 0800 435 455 Asian Helpline: 0800 9177 416 Chinese helpline: 0800 0304 236 www.bereavement-trust.org.uk British Association of Counselling and Psychotherapy (BACP) Find a professionally qualified counsellor in your local area. NB If you are accessing the BACP website, go to the 'Find a therapist' page. 0870 443 5219 www.bacp.co.uk Compassionate Friends Support for all families bereaved after the death of a child or children. Helpline, 10.00 am to 4.00 pm and 6.30 pm to 10.30 pm. 08451 232304 www.tcf.org.uk The Compassionate Friends (open daily 10.00 am to 4.00 pm and 6.30 pm to 10.30 pm) National Office: 08451 203785 Email: info@tcf.org.uk Also has an extensive range of leaflets and a postal lending library for books, audio and video tapes. SOS can put parents in touch with other parents who have lost children 15

through suicide. Library tel: 01634 814146 Library email: library@tcf.org.uk The Compassionate Friends also runs: Support in Bereavement for Brothers and Sisters (SIBBS) Helpline:08451 232304 (opening times as above) Counselling Directory Search on postcode for a qualified counsellor in your area. www.counselling-directory.org.uk/bereavement.html Inquest Advice to bereaved families facing an inquest 020 7263 1111 www.inquest.org.uk The Samaritans Confidential emotional support for people who are experiencing feelings of distress or despair. Helpline, 24 hours a day, 7 days a week. 08457 909090 www.samaritans.org.uk Rotherham 01709 361717 Doncaster 01302 327474 Scunthorpe 01724 860000 Sudden Death Support Association Helps relatives and close friends of those who die suddenly. 01189 733 939 www.patient.co.uk/showdoc/26739250 16

Childhood Bereavement Network Database of information about sources of support for bereaved children 0207 843 6309 www.childhoodbereavementnetwork.org.uk Winston's Wish Practical support for bereaved children, young people and their families, publications. 01242 515 157 www.winstonswish.org.uk SSAFA Forces Help-www.ssafa.org.uk National charity helping serving and ex-service men, women and their families in need. SSAFA Forces Help 19 Queen Elizabeth Street London SE1 2LP Tel: 020 7403 8783 Papyrus Prevention of Young Suicide 67 Bewsey Street Warrington Cheshire 01925 572444 Mon- Fri 9.00 5.00pm Hopeline UK 0-800 0684141 Reading Materials When sudden death occurs Produced by Department of Constitutional Affairs and available at www.dca.gov.uk 17

Help is at Hand www.dh.gov.uk Tel: 0300 123 1002 E-mail: dh@prolog.uk.com DH Publications Orderline, PO Box 777, London SE1 6XH quoting 286523/Help is at Hand 18

APPENDIX B Dear Firstly can I offer my sincerest condolences to you following the loss of [INSERT NAME). Can I also apologise for this unexpected letter sent to you. My name is [INSERT NAME] and I am [INSERT JOB TITLE] for Rotherham Doncaster and South Humber NHS Foundation Trust (RDaSH). I am writing to you as I have been asked to conduct an investigation following the death of your [INSERT RELATIONSHIP]. I would like to express my sincere apology that this event has occurred and for your loss. This investigation is part of the normal procedure that is instigated when any serious event occurs, and is undertaken in order to review the care given,to identify if there were any areas of good practice in the care provided, or if there are lessons to be learned in order to prevent any future incidents of a similar nature As part of the investigatory process we contact the family of the person involved in order to seek out their views and opinions, to ask questions and for you to have the opportunity to obtain information and to express your feelings which we feel is an important part of our investigation. We will then share our findings with you. To support anyone involved in an incident the Trust follows the Being Open and Duty of Candour Policy, which lays out the actions we will be taking. I appreciate that this may be an unwelcome at this time however I feel it is important to contact you and ascertain if you wish to speak to me about any of the circumstances surrounding the tragic loss of [INSERT NAME]. If you would like to meet in person this can be arranged at a time and place most convenient to yourself, I am happy to meet at your home if you would prefer. My contact details are as above. Telephone: [INSERT NUMBER] If you wish to speak to me please contact on the above telephone number so I can arrange a convenient time to meet you. If you do not wish to speak to me at this time but wish to have contact in the future I am happy to arrange this. I have enclosed a booklet that may be of assistance to you at this difficult time. Once again, can I apologise for any distress this letter may cause. Yours sincerely

Mortality Reporting and Review Process (Version 7) Clinical services receive notification of death for a patient where we are the main care provider Guidance Inserts for the Mortality Report and Review Process The Trust provides a wide range of clinical services across inpatient, community and other provider organisations and this can lead to both a degree of confusion as to who is responsible for the reporting and investigating of a patient s death and the risk of double reporting and investigation. To support staff in their decision making staff should refer to the following guidelines. However if there is any doubt staff should contact their line manager for advice. A We are the main provider if at the time of death the patient was subject to: An episode of inpatient care within our service. An episode of community treatment under CPA. An episode of community treatment due to identified mental health, learning disability or substance misuse needs. A Community Treatment order. A conditional discharge. An inpatient episode or community treatment package within the 6 months prior to their death (Mental Health services only). Guardianship B Patients who meet the above criteria but are inpatients within another health care provider or custodial establishment at the time of their death. In these circumstances the death will be reported by the organisation under whose direct care the patient was at the time of their death. That organisation will also exercise the responsibilities under duty of candour. However there will be a discussion to agree on if it is to be a joint or single agency investigation ( this will be determined by the cause of death) and in the case of joint investigations who the lead organisation will be. C Services provided by the Trust where we are not classed as the main provider. For the following services the Trust is only providing a small component of an overarching package of care and the lead provider is the patients GP. Tissue viability Dietetics District Nursing The drug and alcohol shared care services Care home liaison Acute hospital liaison Community physiotherapy Macmillan Nurses (now referred to as the Specialist Palliative Care team) Health Visitors Podiatry D Exception. In addition to the above if any act or omission on the part of a member of Trust staff from one of the services where we are not classed as the main provider is felt to have in any way contributed to the death of a patient, an investigation will be undertaken by the Trust. Also there may be deaths which do not meet any of the above criteria but require investigation due to clinical complexity or other reason. For all deaths of under 18 years The death will be subject to the Child Death Review Process 2008 IR1 Form Completed and Manager Informed For all LD Deaths LEDER notification to be completed and submitted For expected deaths due to natural causes IR 1 to be reviewed by at least Band 7 manager to ensure death was expected,and that the care provided by the Trust was suitable and sufficient. Issues Identified No Manager to complete IR1 documenting the review. Yes For unexpected deaths, but due to natural causes Complete incident appraisal form Incident appraisal form to be reviewed by Care Group Triumvirate Death Reported to the Coroner No Assessed that full SI investigation needed No Hospice Due to the nature of the service provided by the hospice the only deaths which are reportable under this process are those which occur during the 1 st 24 hours of admission or which meet the criteria for the coroner. Request to be made to Clinical Service Manager for investigator to be nominated Concise RCA to be completed within 4 weeks and completed form submitted to Trust Patient Safety Team and attached to IR1 Yes Yes Any required action agreed For unexpected deaths or Deaths which meet the criteria of the coroner If notification form has not already been done, the coroner must be informed of the death if patient is: Patient Suicide Suicide of a person within 6 months of discharge from service Subject to detention under MHA 1983 including CTO Under 18 Deceased due to occupational injury/disease Homicide Unexplained Team manager completes STEIS log and submits to the Trust Patient Safety Team within 24 hours Full SI investigation to be undertaken = Follow SI process and time frames Any required action agreed IR1 Closed APPENDIX C Date: 06/06/2017