LEARNING FROM DEATHS POLICY SEPTEMBER 2017

LEARNING FROM DEATHS POLICY SEPTEMBER 2017 Learning From Deaths Policy_RM09_V1

Policy title Learning from Deaths Policy Policy RM09 reference Policy category Corporate Relevant to Clinical Staff Date published September 2017 Implementation September 2017 date Date last August 2017 reviewed Next review September 2018 date Policy lead Laura McMurray, Risk and Patient Safety Manager Contact details Accountable director Approved by Email: laura.mcmurray@candi.nhs.uk Caroline Harris-Birtles, Director of Nursing Clinical Advisory Group and Mortality Review Group Ratified by: Document history Quality Committee 19 September 2017 Date Version Summary of Amendments Sept 2017 V1 New Policy Membership of the policy development/ review team Consultation Medical Director, Director of Nursing, Head of Governance and Quality Assurance, Risk and Patient Safety Manager and identified staff Members of the Clinical Advisory Group and Mortality Review Group, Deputy Medical Director, Targeted staff DO NOT AMEND THIS DOCUMENT Further copies of this document can be found on the Trust intranet. 2

Contents 1 Introduction 4 2 Scope of the Policy 4 3 Aims and Objectives 5 4 Duties and Responsibilities 6 5 Definitions 6 6 Process for learning from death 9 7 Training 12 8 Dissemination and Implementation Arrangements 12 9 Monitoring and Audit Arrangements 12 10 Associated Documents 12 11 References 12 12 Review of the policy 13 13 Appendices Appendix 1: Letter for families and carers 14 Appendix 2: Case Record Review Flowchart 15 Appendix 3: Case Record Review Form/Guidance 16 Appendix 4: Equality Impact Assessment 23 3

1. INTRODUCTION Following events in Mid Staffordshire, a review of 14 hospitals with the highest mortality rates noted that the focus on aggregate mortality rates was distracting Trust boards from the very practical steps that can be taken to reduce genuinely avoidable deaths in our hospitals. This was reinforced by the recent findings of 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. It found that learning from deaths was not being given sufficient priority in some organisations and consequently valuable opportunities for improvements were being missed. The report also pointed out that there is more we can do to engage families and carers and to recognise their insights as a vital source of learning. There is an increased drive for Trust boards to be assured that deaths are reviewed and appropriate changes are made to ensure patients are safe. Focusing attention on the factors that may have contributed to a patient s death will impact on all individuals within C & I, focusing on the quality of service and care based provision within services as well as identifying early recognition and escalation of a deteriorating patient. Retrospective case record reviews will provide reassurance to the families of the deceased, the care providers and the Boards of NHS organisations that any particular death is not a cause for concern in terms of quality of care provided and to identify areas for improvement, in health care provision in the hospital environment and inform the appropriate individuals who can deliver the necessary changes. Greater levels of assurance will be provided to the trust board by integrating the mortality review structure into the governance framework. This will sit alongside other quality assurance measures including incidents and complaints that monitor the quality of care, sharing of good practice and learning from mistakes. 1.1 Trust Policy Statement The Trust is committed to learning from all incidents and concerns raised relating to its services delivered and the management of patient care. Al staff are guided by the Trust s cultural pillars: Be connected, Be empowerment, keeping things simple and valuing each other, in ensuring that care and treatment is appropriate and that as we Trust we learn from experience and feedback from our service users and others. expected behaviours 2. SCOPE OF THE POLICY 4

This policy relates to all staff and staff groups who may be involved in the mortality review process; Staff groups include: 2. Medical Staff 3. Senior Nursing Staff 4. Quality Improvement Staff 5. Governance Staff Case Record Review parameters: All deaths where bereaved families and carers, or staff, have raised a significant concern about the quality of care provision. All in-patient, out-patient and community patient deaths of those with learning disabilities (using the LeDeR review process) and with severe mental illness. All deaths in a service specialty, particular diagnosis or treatment group where an alarm has been raised with the provider through whatever means (for example through concerns raised by audit work, concerns raised by the CQC or another regulator). All deaths in areas where people are not expected to die, for example suicide/selfinflicted death; and homicide. All deaths that occur that are untimely but may be expected e.g. some people who misuse drugs, are dependent on alcohol or with an eating disorder. Consideration of the appropriateness of review for deaths involving maternal death and stillbirth. Deaths where learning will inform the provider s existing or planned improvement work, for example if work is planned on improving risk planning, relevant deaths should be reviewed, as determined by the provider. To maximise learning, such deaths could be reviewed thematically. A further sample of other deaths that do not fit the identified categories so that providers can take an overview of where learning and improvement is needed most overall. This does not have to be a random sample, and could use practical sampling strategies such as taking a selection of deaths from each weekday. The mortality review process forms one aspect of the Trust s quality improvement work. The Serious Incident Framework (2015) sets out how to identify monitor and investigate incidents defined as Serious Incident s (SIs). This may or may not involve the death of a Service User. Please refer to this policy for further guidance when a death has been agreed as an SI. 3. AIMS AND OBJECTIVES This policy sets out the process for reviewing all deaths of patients receiving a service from Camden and Islington NHS FT or who have been discharged by the Trust up to six 5

months previously, although patients discharged beyond this period will be considered if there is a rationale for doing so. The aim of this policy is to: Clarify when and how families and carers are contacted following the death of a service user and establish guidance around their involvement throughout the governance process. Outline the method of review, how deaths are selected for review and what the scope of deaths for review should be. Clarify which deaths require investigation under the Serious Incident framework. Clarify how to identify opportunities to improve patient safety and quality of care. Recognise the need to consider mortality rates and national mortality indicators, available at diagnosis and individual patient level, to ensure that deaths are reviewed and patients are safe. 4. DEFINITIONS Mortality rate The frequency of death in a defined population during a specified time interval; the per capita death rate in a population; the reciprocal of the population life expectancy. Case Record Review A structured methodology for retrospective case note review following a patient s death to establish whether the clinical care the patient received was appropriate, provide reassurance on the quality of care and identify learning, plans for improvement and pathway redesign where appropriate. Mazars Mortality Categorisation system A framework which helps organisations and staff think through how to categorise whether a person died from natural or unnatural causes and which of these deaths would benefit from further investigation. 5. DUTIES AND RESPONSIBILITIES Medical Director on behalf of the Trust Board Takes responsibility for the learning from deaths agenda pays particular attention to the care of patients with a learning disability. 6

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 be difficult for an organisation to conduct an objective investigation due to its size or the capacity and capability of the individuals involved. 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, involving bereaved families and carers and using information from the actions identified following reviews and investigations to inform quality improvement and contracts etc. n Executive Director. To take oversight of the process described above. Head of Governance and Quality Assurance Ensure appropriate governance is in place in relation to the mortality review process. 7

Work with the Mortality Review Group (MRG) and Risk and Patient Safety Manager to ensure all process and reporting requirements linked to the mortality review are accurate and completed in a timely manner. Mortality Review Group (MRG) Provide assurance to the Trust Board on patient mortality based on review of care received by those who die. Agree and approve the case record review. Will discuss what their opinion of the avoidability of death score based on the case record review and discuss this as a group before seeing the judgement by the reviewer ensuring that the final avoidability of death score and comment has a more robust basis. Identify areas of high risk and agreeing and monitoring improvement plans. Ensure that feedback and learning points are shared with the division and specialities so that the learning outcomes and action points are included in speciality audit programmes as appropriate. Ensure cross divisional learning from mortality review. Risk and Patient Safety Manager Chair the MRG. Offer advice to colleagues involved with the mortality review process. Feedback concerns raised at MRG to relevant specialities. Use the Trust incident reporting system (Datix) to track and report on all deaths that occur within Camden and Islington NHS Foundation Trust. Raise any identified risk onto the Trust risk register where it will be reviewed as part of the risk management process. Feedback learning points identified from the mortality review process. Timely review of deaths once these have been reported via Datix and a decision made on whether a case note review is required. Identifying clinicians to complete the case record review. Ensuring that Duty of Candour requirements is completed. Ensuring that patient s families and carers are given the opportunity to be engaged with the review process, including providing feedback on the outcomes of the review as appropriate. Ensuring all deaths are reviewed at the MRG. Ensuring that all pertinent cases and findings from Case Record Reviews are presented by the appropriate service leads at team meetings. Ensuring that findings are evaluated and reported at divisional quality meetings to promote learning. Feeding back findings from the case record reviews to the MRG. Governance Team Be responsible for the dissemination of case record reviews for all deaths within a division. Ensure these are completed by nominated managers. Individuals reviewing the cases for which they had sole clinical responsibility should be avoided; ideally the case should be reviewed by a clinician not directly involved in the case. 8

Recording case record review data on Datix, specifically the avoidability of death score and the reason for making this judgement. Recording Mazars type of death score on Datix. Producing reports based on information recorded in Datix. Maintaining a library of completed case record review forms and feeding back the reports and outcomes to the clinical leads for each area. Analysis of the database to identify themes and trends. Ensuring learning outcomes and action points are included in the speciality audit/improvement programmes as appropriate. Support the review process with any identified Duty of Candour requirements. Trained Investigators for Learning Disabilities Mortality Review (LeDeR) Programme. Following identification of a death of a patient with learning disabilities through the case record review process, a specialised investigator for the LeDeR programme will be notified. They will then be able to follow their own process of review and inform the MRG of the outcome. Divisional Clinical Director Ensuring that all pertinent cases and findings from case record reviews are presented at team meetings. Ensuring that outcomes and learning from team meetings are recorded and the action plans for improvement are developed where required. Leads are identified for implementation of action points within action plans. Overseeing progress on the implementation of action plans and keeping governance informed. Team Managers Ensuring that all deaths are reported on the Trust incident reporting system (Datix) and are completed in an accurate and timely manner. Completion of case record reviews within 72 hours of the incident being reported. Return the completed mortality review form to the Governance team (as directed on the form). All Staff Reporting all deaths on the Trusts Incident Reporting Software (Datix). Cooperating in case record reviews and any further investigation required. 6. PROCESS FOR LEARNING FROM DEATH 6.1 Mortality Review The aim of the mortality review process is to: 9

Identify opportunities to improve patient safety and quality of care. Improve the experience of the bereaved families and carers through better opportunities for involvement in investigation and reviews. Enable informed reporting with transparent methodology. Promote organisational learning and improvement. The process for the conduct of mortality reviews is outlined in the flow chart as described in Appendix 2. Key steps are described below: 6.1.1 tification of patient deaths Patient deaths are reported on Datix by the clinician involved in that patient s care or by the clinician that the death has been reported to. Information included in this report must include cause of death or circumstances surrounding the death. It must also include a brief description on the treatment that person was receiving by the service last involved in that patient s care. Checks are made on this information by the Risk and Patient Safety Manager using Carenotes. Following a review by the Risk and Patient Safety Manager a case record review is requested from the manager of the service for all deaths identified in section 4. If there is any identified duty of candour issue the mortality reviewers should act according to the guidance identified below. 6.1.2 Case Record Reviews Assessment of clinical coding should be part of the case record review but the primary focus should be to provide assurance on the quality of care. The Peer reviewer should ensure that the patient s family and/or carer has been contacted and given opportunity to be engaged in the review. The Duty of Candour Policy contains advice on how to approach this. The peer reviewer should follow the instructions within the case record review to ensure proficient completion. A training package is currently being developed to support this. The case record review should be sent to the Risk and Patient Safety Manager to collate and analyse on Datix. Quality and data outcome of case record reviews will be overseen by members of the MRG to manage assurance of inter-rater reliability. 6.1.3 Contact with Family and/or Carers When a death occurs on Trust property it is the duty of the police to inform the family and carers of a patient death. A member of the team that knew the patient then contacts the family and/or carer by phone to offer condolences. For deaths where a case record review is required a letter is then sent out by the team (See appendix 1) to offer the opportunity to meet by phone or in person at a place of their convenience to discuss any issues or concerns the family may have and to explain the process of what happens next. 10

When this meeting occurs the family and/or carer will receive a pack which includes information about the governance processes involved following a death, managing bereavement and contact numbers for support and advice following bereavement. It is explained to the family and/or carers that their understanding of the care that was provided by the Trust is crucial to the case review process and their input will help the MRG panel with their decision of whether further investigation is required. The family and/or carer will be kept informed if further investigation is required and be contacted by the lead investigator for their input. 6.1.4 Reporting and Learning A dashboard data template will be used for reporting. This must include total number of deaths in the Trust, total number of deaths subject to case record review and total number of deaths assessed to have more than 50% chance of being avoidable. Any identified sub optimal care, actions to prevent reoccurrence and learning and views from relatives will be shared to support learning. This dashboard data will be reported to the Trust Board on a quarterly basis. Individual reviews on completion will be reported and discussed at Divisional Quality forums and where necessary action plans developed. Where there is learning for teams and the Trust this will be highlighted and shared across the organisation in learning lessons bulletins and workshops. 6.1.5 Further Investigation Members of the MRG will appraise the case record review and decide whether a death is a Serious Incident meaning further investigation is required. The Management of Serious Incidents Policy (April 2016) sets out the Trust s approach to the managing, investigating and learning from serious incidents when they happen. Deciding whether an incident should be declared a Serious Incident is supported by the Serious Incident Framework but also involves judgment. This means there will sometimes be discussion about whether a particular death constitutes a Serious Incident. Key factors that are taken into consideration include Concerns about care have been raised by the family or carer Evidence that the care delivered did not meet the national standard of care The death occurred on a ward If the person is under section status when they die The person had been identified as having a Learning Disability Whether a health condition that leads to the death was aggravated by the person s mental health and if care provided could have prevented this. If the death appears to be caused by suicide. How close the death was to the last contact with the trust. 11

Whether the death related to child, still births, maternal death Whether an SI will provide learning for service improvement 6.2 Method of Review Refer to Appendix 3 for process 7. TRAINING The Trust is making arrangements to have in place a training package to meet the needs of staff in delivering the requirements of this policy. In the interim, case record review will be integrated into the Trust current serious incident review training. 8. DISSEMINATION AND IMPLEMENTATION ARRANGEMENTS The policy will be disseminated via the Trust Intranet/Website and other channels used by individual teams. The Trust implementation tool will be completed to highlight the key messages. An implementation tool will be developed to highlight the key messages for implementation. 9. MONITORING AND AUDIT ARRANGEMENTS Quarterly reports will be generated as part of other governance reports generated by the Governance Team. An effectiveness review of the process will be carried out annually The Quality Committee will receive quarterly updates on progress with the process The Board appointed NED and Director lead who will feedback to the Board on a quarterly basis 10. ASSOCIATED DOCUMENTS Death on Trust Premises Policy Trust Management of Serious Incidents Policy Trust Being Open and Duty of Candour Policy 11. REFERENCES NHS England, Mortality Governance Guidance Morbidity & Mortality Meetings: A guide to good practice, Royal College of Surgeons (2015) 12

Care Quality Commission (December 2016), Learning, candour and accountability: a review of the way NHS trusts review and investigate the deaths of patients in England Higginson J, Walters R, Fulop N, BMJ Qual Saf (2012), Mortality and morbidity meetings: an untapped resource for improving the governance of patient safety? 12 REVIEW OF THE POLICY This policy shall be reviewed in twelve months 13

Appendix 1- Letter to family and carers. Address Address Address Address Address Address Address Address Date XXXX Dear Patient/Relative (as appropriate), You/Your. (insert relative) have/has been involved in an incident... describe event here... I wish to express my sincere apology that (what is the event?) has occurred. The Trust aims to provide a service of quality to you/your (relatives as appropriate) and to examine incidents promptly and share findings with those involved. 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. We would like to invite you/your (relatives as appropriate), if you wish, to attend a meeting to provide a step-by-step explanation of the events and circumstances. Prior to this going ahead, I would appreciate your view on the following, in relation to this meeting. Your preference of time and date of meeting? Where would you wish to meet/proposed venue if there is any reason that this cannot be at the hospital or Health care centre? If you wish to do so, please feel free to bring along a friend or relative to offer you support during this meeting. Also, if you wish, following the meeting you will be provided with further information relating to the outcome of this initial enquiry. If you would prefer not to attend any meetings please let us know. When our investigation is completed we will write to you to provide feedback regarding the outcome. I/ Staff member XXXXX is acting as your lead contact for the duration of the being open process. I/they can be contacted on telephone number xxxx xxxxxxx Yours sincerely Manager 14

Appendix 2- Case Record Review Flowchart Death of patient identified and reported on Datix. Reviewed by Risk and Patient Safety Manager for immediate Death reviewed by Risk and Patient Safety Manager and case record review requested if there are any concerns identified. To be completed within 72 hrs by service manager. All deaths are reviewed by the Mortality Review Group. All deaths categorised using the Mazars system. further action required More information is required by MRG members for decision to be made. Further investigation required. Refer to Management of Serious Incidents Policy (2016) Case record review uploaded onto Datix Monthly Mortality Report presented to MRG, Divisional Quality Meetings and Quality Meeting 15

Appendix 3 CASE RECORD REVIEW FORM This review should be completed by a senior manager and returned to the Governance and Quality Assurance Department. Should there be learning or further follow up, this document may be shared more widely within the Trust. Guidance on completing the review is contained at the end of the document. People involved Reviewer s Details Division/Team completing review Name of person completing review Date of review Role of person completing review Service User s Details Service user s initials Diagnosis Date of birth Date of death (if applicable) Number of life years lost: Calculated by subtracting the age at death from the gender life expectancy. 79 for males and 84 for females. Learning disability? Length of time in treatment with C&I MHA status Last CPA date Safeguarding? (if applicable) Name of consultant Name of key worker/ care co-ordinator Name of carer/relatives Background information Incident details Incident Date Contact details of carer/relatives Datix. (please give as many facts about the incident as possible) a. Think about how care should have been for this patient and compare it to how care was b. Consider what would have been an acceptable standard of care for this patient and consider how the healthcare received fell below this standard c. Did something happen that could have been averted by different management? d. Would this have happened under your watch? e. Would you be happy if a relative of yours received this standard of care? Names and roles of any witnesses Was a junior doctor involved? Date statements taken Specialty and Grade 16

Were the police involved? Police reference Please give a brief summary of clinical history Timeline of Service User Contact (Brief timeline to include contact with service over past six months) (Detailed timeline relevant to the weeks/days leading up to, and including the incident) Quality of Care and Treatment (please refer only to pre-incident reviews; any postincident reviews can be referred to in the Immediate action/learning section below) Question Yes / Evidence Please describe the Careplan Is there evidence that the care plan was being followed? Please describe the most up-to-date risk assessment? Is there evidence that identified risks were being managed? Had medication been reviewed recently? 17

Were physical healthcare concerns being followed up? Was there appropriate liaison with other organisations? If the service user also had mental health problems, were these being treated appropriately? Have the carer/relatives raised any concerns about the service user s care and treatment? Have carer/relatives been contacted about the incident? Avoidability of Death Score. We are interested in your view on the avoidability of death in this case. 1. Definitely avoidable 2. Strong evidence of avoidability 3. Probably avoidable, more than 50-50 4. Possibly avoidable, less than 50-50 5. Slight evidence of avoidability 6. Definitely unavoidable. The following questions can be useful in helping to identify avoidable deaths: Was the death expected or unexpected at the outset? Was the death related to a healthcare intervention rather than the natural progression of the patient s disease? Did any avoidable events cause harm to the patient Was there a deviation from the accepted norms of practice? Were there extenuating factors that reduce preventability (co-morbidity, nature of acute illness, urgency of situation) Were there mitigating factors which decrease preventability (appropriate use of pressure relieving mattress in case of pressure ulcer, evidence of falls prevention strategies) Consider if better care had a reasonable chance of preventing the patient s death Is there enough evidence to justify your decision Please comment on the reasons for your judgement of the level of availability of harm in this case, including anything particular you have identified: 18

Contact with service user, families and carers post-incident Clinical teams are required to make contact with the service user involved in the incident, to offer to meet with them to speak about what has happened and explain that they have the opportunity to be engaged in this review process. Where the service user lacks capacity to make decisions about their care, or has died, this contact should be with the person s next of kin. Service users and family members should be given a named contact within the clinical team for any queries. Name (and relationship) of person contact made with Dates, method of contact Have they had the opportunity to comment on their view of the treatment received by their family member? Summary of matters discussed Service user / family member contact details Designated contact person in clinical team Duty of Candour In addition to the expectation that service users and families will be contacted in all incidents, the Trust has an obligation to meet certain requirements under Duty of Candour. Was this incident an unexpected or unintended incident that appears to have resulted in: - Death of the service user; - Impairment of sensory, motor or intellectual functions likely to last for a continuous period of more than 28 days; - Changes to the structure of the service user s body; - Prolonged pain; - Prolonged psychological ham; OR - Shortened life expectancy Did the consequences of the incident require professional treatment to prevent: - The death of the service user; OR - Any injury, which left untreated, would lead to any of the outcomes above. Yes / Yes / If the answer to either question above is YES, then this incident meets criteria for Duty of Candour and the following section must be completed. 19

Have the team: Y/N Date Met with the service user / family / NOK in person Spoken with the service user / family / NOK if meeting has not been possible Offered an apology Provided information about the facts of the incident known at this stage Advised the family / NOK that there will be an investigation to understand what has happened and to learn lessons for the future Followed this up in writing to the service user / family / NOK (Please submit a copy with this preliminary review) Completed an after action review or debrief within the team? Please supply date(s). If any steps have not occurred above, please state the reasons, and actions taken to address this here. All steps above are mandatory. Outcome of preliminary review Immediate actions / learning already implemented Action / learning 1 2 3 Further recommendations and issues identified from this preliminary review Recommendation / issue identified for the team or Trust 1 2 3 20

Case Record Review Guidance Why have I been asked to complete a case record review? - A death has been reported by your team has been identified as a potentially serious incident, or an incident from which learning may be gained, under the trust-wide Learning From Death - The case record review allows the Trust to ascertain the facts known about the incident, ensure that all processes have been followed, and to determine whether any further follow up (e.g. a serious incident investigation is required). What happens next? Once you have completed the case record review, the next steps are: The contents of the review will be reviewed by a Risk and Patient Safety Manager In accordance with the Learning From Death Policy, National Serious Incidents Framework and the trust-wide Serious Incidents Management Policy, will make a recommendation for any follow up required. The options are: further action Short management report Level 1 investigation Level 2 investigation further follow up is required A serious incident investigation is not required, but you will be asked to write a brief cover note summary, which will be shared within the Trust, alongside this preliminary review A serious incident investigation will be undertaken, by a lead investigator from another division of the Trust A serious incident investigation will be undertaken by a panel, chaired by somebody external from the Trust 21

This recommendation is reviewed by the Medical Director, Chief of Operations and the Director of Nursing, who will decide the level of follow up. Is there anything else I need to do? Consider whether you have: Acted on immediate findings, including intervening to ensure safety; Ensured compliance with Duty of Candour; Made referrals to occupational health for any staff members affected by the incident and requiring this. Consider consulting the Trauma at Work Pathway if necessary; Arranged a debriefing for staff members involved; Ensured patients involved or who witnessed the incident, have had an opportunity to discuss it with staff members; Collected any outstanding statements and submitted these to the Governance and Quality Assurance Team; Updated care plans and risk assessments in light of the incident. If you have any queries, please contact the Governance and Quality Assurance Team. 22

Equality Impact Assessment Tool Appendix 4 Yes/ Comments 1. Does the policy/guidance affect one group less or more favourably than another on the basis of: Race Ethnic origins (including gypsies and travellers) Nationality Gender Culture Religion or belief Sexual orientation including lesbian, gay and bisexual people Age Disability - learning disabilities, physical disability, sensory impairment and mental health problems 2. Is there any evidence that some groups are affected differently? 3. If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable? 4. Is the impact of the policy/guidance likely to be negative? 5. If so can the impact be avoided? 6. What alternatives are there to achieving the policy/guidance without the impact? 7. Can we reduce the impact by taking different action? N/A N/A N/A N/A 23