The West of England AHSN in collaboration with eight acute trusts were one of the early implementers of the structured review and have developed a best practice framework to support trusts in adopting the Royal College of Physicians’ (RCP) National Mortality Case Record Review Programme.
All acute trusts have systems in place to ensure patient safety and quality of care. Many of these include ways of reviewing hospital deaths, often by detailed review of the case notes, to identify areas that could be improved. However, until this project (in 2016 and 2017) there was no standardised approach to reviewing deaths and reviews have been limited to deaths occurring in the hospital setting.
‘Together, we aim to ensure that a system which reviews all deaths of elective patients and a proportion of those admitted as an emergency is established by all acute hospital trusts in the West of England, so that learning from such reviews, results, as appropriate, in improved health services delivery’.
Christine Teller, a public contributor involved in the project
The roll-out was delivered in two phases, with the Cohort 1 Trusts trained in October 2016 with the remaining trusts receiving their training in summer 2017.
Please note that the documents available for download below were current at the time of training in 2016 and 2017.
- Slide deck from the Royal College of Physicians and training case notes guide.
- Example case notes from train the trainer events. Case note 1; Case note 2; Case note 3.
- Data collection form.
- Frequently asked questions.
- Using the structured judgement review method: A clinical governance guide to mortality case record reviews.
- Using the structured judgement review method: A guide for reviewers.
- Example evaluation form.
- The science background.
Useful resources generated through the West of England mortality reviews collaborative:
- Samples of Trust policies for Gloucestershire Hospitals, Salisbury Hospital, North Bristol Trust, and UH Bristol.
- Sample of operational process flows.
- Samples of presentation slides at Dr Foster, London and Wessex Safety in Emergency Surgical Practice conference, Southampton. Guest slides kindly shared by Neil Pearce, Southampton Hospital.
Useful resources generated through the National Quality Board:
It has been acknowledged that the NHS can improve the way we engage with families and carers when things go wrong and as part of the national Learning from Deaths programme the National Quality Board has released guidance for trusts on working with bereaved families. The guidance advises trusts on how they should support, communicate and engage with families following a death of someone in their care.
Recognising that families will also need some help and guidance at what can be a very difficult and distressing time, this template can be used for trusts to generate a local leaflet which gives the family practical advice, support and information following the death of someone close to them.
- Patient Safety Journal article from March 2019 on the collaborative approach that the West of England AHSN took to implement Structured Judgement Reviews in the region.
- 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.
- Healthcare Safety Investigation Branch.