Learning from deaths

We think it’s important that we learn as much as we can from deaths which take place in our care.

We believe that this is important so that:

  • we can explore whether there are areas we can learn from which change the way we treat or care for other patients;
  • we can improve our approach to offering the best possible experience for patients who are approaching the end of their lives, and improve our support for their families and carers.

To support us in learning from deaths, we use a mortality review process to look at deaths which take place while a patient is an inpatient with us.

How we review deaths

Each of our specialties has a mortality lead, who is a clinical member of staff responsible for managing the mortality review process in their area of work.

Assessing care

Our mortality leads consider deaths which take place while a patient is under our care on one of our wards. This involves them looking at the information that is registered about the patient’s death, and assessing the appropriateness of the care that the patient received.  This is called a Level 1 mortality review. We do this for all deaths which take place while a patient is an inpatient with us.

If the mortality lead has reason to think that we might be able to learn more from looking more closely into the patient’s care, they will request a more in depth, formal assessment. This is known as a Level 2 mortality review.

Reviewing care

As part of the Level 2 review, a group of clinical staff come together in a peer review meeting to consider the care that the patient received. The group will include a range of clinical staff, such as consultants, junior doctors, nurses, and therapists. They use a structured set of questions to better understand the circumstances under which the patient died, and whether we can learn anything from care we provided.

When we perform a Level 2 mortality review

NHS England requires us to automatically request one of these more detailed reviews of a patient’s care if:

  • a patient’s family or carers have raised significant concerns about the quality of their care
  • any member of staff  thinks that a patient’s care might have had a different outcome if it had been managed differently
  • there are any other concerns about the service, specialty, or method of treatment involved in caring for a patient at the time of their death (such as if a service were to have an unusually high mortality rate)
  • a patient died unexpectedly
  • a patient had been being treated under a section of the Mental Health Act
  • a patient had a learning disability
  • a patient was a baby, child or young person
  • a patient was pregnant or had given birth very recently
  • a mother has experienced a stillbirth

In addition, we require our mortality leads to request a detailed, Level 2 review if:

  • a patient had died while in hospital for planned (elective) care
  • a patient’s care is being investigated by the Coroner
  • a patient had received surgery within a year of their death
  • a patient died within 30 days of leaving hospital (in the cases where we learn about this happening)

What happens once a death has been reviewed

We will share any learning from the review with our clinical teams so that it can help us improve our care.

We will publish a report every quarter which summarises the findings of the mortality reviews for that period of time, and which will help us to identify any themes or trends which might help us to improve our care.

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