In 2016, the Care Quality Commission (CQC) published a report which looked at how NHS trusts review and investigate the deaths of patients in England (read full report here). The findings of this report highlighted that families and carers often have a poor experience of investigations, that the quality of investigations is variable and inconsistent and crucially, that these issues act as a barrier to identifying opportunities for learning.
At the time the CQC report was published, the CQC’s former Chief Inspector of Hospitals, Sir Mike Richards, said “The extent of the problems is more than I expected. The whole system [of investigating deaths] needs an overhaul at national level and local level.”
In response, the government outlined a series of new requirements that all NHS trusts and foundation trusts are now required to meet. Read more about these requirements. The requirements include:
In March 2017, new detailed national guidance about the new Learning from Deaths requirements produced by the National Quality Board (NQB), was published by NHS England. Read full report here.
The guidance stipulates a number of specific requirements all trusts must meet. These include:
Case note review methodology
Every NHS trust is now required to produce a new policy document detailing its approach to responding and learning from deaths of patients who die under its management and care. This must include details of the approach and methodology to undertaking case record reviews, including for mental health trusts, deaths of people with learning disabilities and for neonatal and maternal deaths. The guidance is clear that bereaved families should be involved in the review process and fully supported and engaged with throughout.
Publication of data
Trusts are now required to collect and publish detailed information on deaths on a quarterly basis through a board paper and an agenda item at the public Board meeting.
These changes make the NHS the first healthcare system in the world to commit to reporting and publishing information on the number of avoidable deaths in its hospitals and the work that is being done at a local level to learn from those deaths.
The government has confirmed that adherence to these guidelines will be closely scrutinised by the CQC as part of all future inspection activity. More importantly though, these changes reflect a recognition that we need to learn from all deaths in healthcare, that it’s no longer acceptable to view any death as “one of those things” and that every death requires an open and honest review so that opportunities to learn and improve care for the future aren’t missed. These changes will help ensure healthcare organisations locally are able to take a wider view of any trends and take a more proactive approach to reducing avoidable harm.
Datix has developed a Mortality Review module specifically designed to help learning from deaths by capturing, reviewing and reporting all mortalities in one system:
Datix has created a system designed to meet all the requirements of the new Learning from Deaths guidance and is configurable to the exact needs of individual organisations. It allows organisations to conduct mortality reviews locally, detail actions to move forward and identify lessons learned, ensuring you are compliant with all of the CQC requirements.
The module is powerful on its own, but it also operates within the wider data collection capabilities of the Datix Cloud IQ platform. Users can delve into a greater level of detail with a link to the Investigations module, which provides tools into root cause analysis for adverse events and highlights recommendations for areas of improvement. Evidence of learning and improvement are available all within the one Datix Cloud IQ system.
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