Most people who come into contact with the NHS receive excellent care and return to their home, previous lifestyle and family life.
Unfortunately, for some people this may not be the case. Despite advances in medical care and receiving the very best quality of care, death can sometimes sadly occur.
We think it is important for us to review all deaths within the Trust. This helps us to understand what happened and if there is any learning or changes in practice that we need to consider or any examples of excellent care that we could share with others.
The Trust has been undertaking reviews into the death of patients for some time and this is something that is well established across our clinical services. The importance of this has been highlighted nationally and is well regarded as contributing to improved patient care.
The National Plan
In December 2016, the Care Quality Commission published a report called ‘Learning, Candour and Accountability: A review of the way NHS Trusts review and investigate the deaths of patients in England’. The report found that learning from deaths was not given sufficient priority in some organisations across the NHS and as a result, valuable opportunities for improvements were being missed. In response, guidance on a new national Learning from Deaths Programme was introduced across the NHS. One of the key requirements was for hospitals to publish a policy on how it responds to and learns from deaths of patients who die under its care. In addition, it also required Trusts to publish information on the outcomes of mortality reviews and how these have led to improvements in care.
Over the past few years, we have worked very closely with other Trusts as part of a Regional Mortality Collaborative. The aim was to develop a process that enabled all of us to review patient deaths using a common approach and with a strong focus on learning, support and solving problems together. This important work still continues today within the North East network of hospitals.
Learning from Deaths dashboard
Each quarter, the Trust presents a ‘Learning from Deaths Dashboard’ to its Board meeting in public. This highlights the outcomes and learning from mortality reviews that have taken place in that period. The national Learning from Deaths Programme is a new and evolving area of work and we anticipate that the dashboard will change over time as we further develop our mortality review processes.
Further information about the national programme can be found on the NHS Improvement website and using the following link - https://improvement.nhs.uk/resources/learning-deaths-nhs/