CQC: Learning from deaths At PAHT, we now have a learning from death process that meets the national requirements. Every death has a level one review by a medical examiner. At least 25% of all deaths are referred for a Structured Judgement Review (SJR) to be undertaken, including all the mandatory reviews and those of our local outliers. All other deaths are reviewed through the local mortality and morbidity process, using a standardised level 2 review template. For any death that has an avoidability score of 1 or 2 (definitely avoidable or strong evidence of avoidability), these cases are referred to the Second Review Panel. There is ongoing work to continually embed the process. Mortality and morbidity workshops have been undertaken in September, along with training on completion of SJRs. The objective is that all specialities will have introduced the new standardised format for mortality and morbidity workshops by the end of October 2020. Total deaths versus number of SJRs completed The graph (top right) shows the number of deaths verses SJRs during this year. The graph (bottom right) shows the number of deaths over a four year period, highlighting the COVID-19 peak in April 2020. At PAHT, we have been below
Themes of mortality data and SJRs.
Total deaths (in month) versus four year average
our average death rate after the peak. This has been seen by NHS trusts across the country, following the impact of the COVID-19 pandemic.
Aspiration pneumonia pathway to be reviewed Four child deaths reviewed in September, these deaths have been discussed at the Incident Management Group (IMG)
The SJRs have identified the following key pieces of learning Positive aspects of care from over the last few months: SJRs include:
Increased admissions of Good communication with end stage oncology families recorded patients Early initiation of and Missed opportunities to delivery of end of life care complete DNACPR and TEPs Work plans to improve patient outcomes Missed opportunities to discuss patients’ preferred There is a learning from deaths place of death work plan to improve patient outcomes, based on our mortality 7
