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.

Themes of mortality data and SJRs.

Total deaths (in month) versus four year average

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.

The SJRs have identified the

Increased admissions of end stage oncology patients Missed opportunities to complete DNACPR and TEPs Missed opportunities to discuss patients’ preferred place of death

Aspiration pneumonia our average death rate after the pathway to be reviewed peak. This has been seen by NHS Four child deaths reviewed trusts across the country, following in September, these the impact of the COVID-19 deaths have been pandemic. discussed at the Incident

following key pieces of learning Positive aspects of care from over the last few months: SJRs include:

Management Group (IMG) Good communication with families recorded

Early initiation of and delivery of end of life care

Work plans to improve patient outcomes

There is a learning from deaths work plan to improve patient outcomes, based on our mortality

data and mortality review findings.

This includes work on the following areas:

End of Life Quality Improvement Programme

Focus on identification and referral to correct pathway

Training and development for all staff involved to improve confidence and capability

Assessment and recording of individualised plans of care

Acute kidney injury (AKI)/ sepsis

Focus on early recognition and early intervention

Business case being prepared to purchase AKI/ Sepsis Safety Track and Trigger tool on NerveCentre

Speciality assessment tool

A baseline audit has been undertaken and shared, with targeted improvements identified to improve documentation and the capturing of comorbidities. The associate medical director for unplanned emergency care is taking forward ongoing monitoring and compliance as business as usual

Acute respiratory pathway including aspiration pneumonia

Implementation of noninvasive ventilation outside of critical care. Two patients have now received NIV on Locke Ward and both patients have responded well to their treatment

Developing solutions for better communication regarding patients feeding at risk

Project group set up and have completed root cause analysis to inform focus for QI work for aspiration pneumonia

Focus on compliance with pneumonia and COPD admission care bundle with early identification and interventions

Fractured neck of femur

Focus on expediting patients safely and in a timely manner from the emergency department (ED) to the hip fracture ward and ensuring an escalation bed on the ward is always available For more information, please contact Nicola Tikasingh, mortality and quality matron: nicola.tikasingh@nhs.net.