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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.

Come back soon for our implementation toolkit and the RCP case study on our collaborative.

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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 Royal College of NursingAvMA 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:


Learning and sharing

Previous events