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Structured Mortality Reviews

We have formed a collaborative with the six acute trusts in the West of England to be an early implementer of the Royal College of Physicians’ National Mortality Case Record Review Programme.

This standardised approach to mortality reviews has been developed by the Royal College of Physicians in partnership with the Royal College of Nursing, AvMA and Datix .

The West of England AHSN’s collaborative has agreed to be one of the early implementers of the structured review and we will develop a best practice framework as a template to support the trusts in this project. The roll-out is planned in two phases, with three early implementers leading with the remaining trusts following in spring 2017. For those interested in the aim of our collaborative and how we plan to work together, we have created a briefing document.

The six trusts in our collaborative are Gloucestershire Hospitals NHS Foundation Trust, Great Western Hospitals NHS Foundation Trust, North Bristol NHS Trust, Royal United Hospital Bath NHS Foundation Trust, University Hospitals Bristol NHS Foundation Trust, and Weston Area Health NHS Trust. We have also had requests from Taunton and Salisbury hospitals to join our collaborative.

While most hospitals undertake some form of mortality review, there is wide variation in terms of methodology, scope, data analysis and contribution to learning. By establishing a consistent process of reviewing care through a structured analysis of patient records, we aim to improve the quality of care by helping hospitals to learn from problems that contribute to avoidable patient death and harm. A short briefing note for patients and the public has been written by one of our public contributors.

We also aim to produce a best practice framework, which utilises intelligence from implementing the standardised notes review from the National Mortality Review Programme to develop quality improvement work across the region.

Concentrating on the factors that cause deaths in hospitals will also impact positively on all patients, reducing complications, length of stay and readmission rates. This is through the mechanism of improving pathways of care, reducing variability of care delivery through the use of care bundles, and early recognition and escalation of care of the deteriorating patient.

Retrospective case record review will identify examples where these processes can be improved and this information needs to be constantly fed back to clinicians. Furthermore, it will be possible to gain an understanding of the care delivered to those whose death is expected and inevitable. In many organisations this group of patients does not receive optimal care, often because the diagnosis (ie “this person is dying”) is not made or the necessary expertise is in short supply.

In time it will be possible to raise awareness amongst clinicians and managers of the need to promote best practice and behaviours, reduce variability, and make the focus on mortality everyone’s business. It should become the subject of formal and informal conversations, from the board room to the coffee room.


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Get involved

If you would like to get involved or want more information, please contact Kevin Hunter. For latest information on the national programme please visit the Royal College of Physicians website.

Learning and sharing

HSJ article from October 2016 submitted by the Royal College of Physicians.

CQC enquiry into the way NHS trusts review and investigate the deaths of patients in England published December 2016 and statement to Parliament by the Secretary of State for Health.

NHS England letter to Medical Directors, December 2015.

Previous events

Sample agenda for local train the trainer event.

Evaluation report from local train the trainer 1 event on 7 October 2016.

Useful resources

The aim of the collaborative and how we plan to work together.

A briefing note for patients and the public.

Please note that the documents available for download below were current at the time of training. Please see the Royal College of Physicians website for latest versions. 

Slide deck from the Royal College of Physicians and supporting notes.

Two example case notes as used in train the trainer 1 event. Case note 1 and Case note 2.

Data collection form as used in train the trainer 1 event.

Using the structured judgement review method: A clinical governance guide to mortality case record reviews  as used in train the trainer 1 event.

Using the structured judgement review method: A guide for reviewers is also available from the Royal College of Physicians website.