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Structured Mortality Reviews

The West of England AHSN in collaboration with eight acute trusts are one of the early implementers of the structured review and have developed a best practice framework as a template to support the trusts in adopting the Royal College of Physicians’ (RCP) National Mortality Case Record Review Programme.

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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 now there has been no one standardised approach to reviewing deaths and reviews have been limited to deaths occurring in the hospital setting.

The Royal College of Physicians in partnership with the Yorkshire and Humber AHSN Improvement Academy and Datix have developed a standardised approach and in the West of England we are early adopters of this approach.

‘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 is being delivered in two phases, with the Cohort 1 Trusts trained in October 2016 and the remaining trusts receiving their training in the summer 2017. All six acute trusts in the West of England and two neighbouring trusts are involved.

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.

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.


Useful resources

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. 

Useful resources generated through the West of England mortality reviews collaborative:

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.


Learning and sharing

Previous events