This was reinforced by the 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 (pdf), published in December 2016. 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 that the NHS can do to engage families and carers and to recognise their insights as a vital source of learning. Its purpose is to help initiate a standardised approach, which will evolve as the health care system learns.
In July 2018, the National Quality Board published the first edition of the Learning from deaths: Guidance for NHS trusts on working with bereaved families and carers (pdf) to help NHS trusts to further develop guidance for bereaved families and carers regarding what local support they can expect when concerns are raise concerns related to the death of their loved one.
2019/2020
| Indicator | Q1: April-June | Q2: July-September | Q3: October-December | Q4: January to March | Year End | Learning Points |
|---|---|---|---|---|---|---|
| Patient Safety: Total percentage inpatient deaths subject to a case record review | 100% | 100% | - | - | 100% | |
| Patient Safety: Total number of in-patient deaths subject to a case record review identifying that there was a problem in care provided | 1 | 1 | - | - | 2 | Serious incident reviews have been undertaken. The learning will be provided in the next Learning from Experience report Trimester 2, 2019/20 |
| Patient Safety: Total percentage of deaths reported by and to the Trust (including inpatient deaths) subject to a case record review | 100% | 97% | - | - | 99% | |
| Patient Safety: Total number of deaths (including inpatient deaths) subject to a case record review estimated due to problems in care | 0 | 0 | - | - | 0 | In response to the high number of case record reviews resulting in no problems in care, the clinical audit programme will be increased from 5% to audit 10% of reviews from April 2019. |
2018/2019
| Indicator | Q1: April-June | Q2: July-September | Q3: October-December | Q4: January to March | Year End | Learning Points |
|---|---|---|---|---|---|---|
| Patient Safety: Total percentage inpatient deaths subject to a case record review | 100% | - | - | - | - | |
| Patient Safety: Total number of in-patient deaths subject to a case record review identifying that there was a problem in care provided | 0 | - | - | - | - | |
| Patient Safety: Total percentage of deaths reported by and to the Trust (including inpatient deaths) subject to a case record review | 34% | - | - | - | - | |
| Patient Safety: Total number of deaths (including inpatient deaths) subject to a case record review estimated due to problems in care | 0 | - | - | - | - |
Trust performance - 2018/2019 (pdf)
2017/2018
| Indicator | Q1: April-June | Q2: July-September | Q3: October-December | Q4: January to March | Year End | Learning Points |
|---|---|---|---|---|---|---|
| Patient Safety: Total percentage inpatient deaths subject to a case record review | 100% | 100% | 100% | - | 100% | |
| Patient Safety: Total number of in-patient deaths subject to a case record review identifying that there was a problem in care provided | 1 | 2 | 0 | - | 3 |
April: Referral pathways implemented for long term conditions to inform specialist nursing/medical care. July: Improved safer transfer of patient care between CWP and acute trust. |
| Patient Safety: Total percentage of deaths reported by and to the Trust (including inpatient deaths) subject to a case record review | 15% | 17% | 18% | 20% | 18% | |
| Patient Safety: Total number of deaths (including inpatient deaths) subject to a case record review estimated due to problems in care | 0 | 2 | 2 | 0 | 4 |
October: Need to review adequacy of systems to reliably contact the District Nursing Service out of hours. November: Improvements required to communication with families in relation to medication regimens in place for people receiving palliative care. |