This presentation includes governance, case record reviews, minimum data collection requirements.

1. Elderly care conference 2017
Stream C – National guidance on learning
from deaths
Mark Barnett

2. National Guidance on Learning
from Deaths
Join the conversation #ECC_BJ

3. Some background
• Post Mid-Staffs review of 14 hospitals with highest
mortality rates noted focus on numbers was distracting
Trust Boards from practical steps which could be taken
to reduce avoidable deaths
• NGLD designed to ‘kick start’ prioritising opportunities
for improvement, engaging families and carers and
using their insights as a source of learning
• Should be read alongside Serious Incident Framework

4. • Issues to tackle:
– Which deaths to review?
– How should the reviews be conducted?
– Time and resource
– Degree of avoidability
– How should Trust Boards use the information?

5. Governance
• Reviews are only useful if findings are shared and acted upon
• Trust governance arrangements and processes should include,
facilitate and give due focus to the review, investigation and
reporting of deaths – with responsibilities at Exec and non-Exec
level
• Staff should have training, skills and protected time to report,
review and investigate deaths
• Ensure there is a clear policy for engagement with bereaved
families and carers

6. Minimum data collection
requirements
• By September 2017 – an updated policy on how Trusts respond to,
and learn from, deaths, including how its processes responds to
death of person with:
– a learning disability
– mental health needs
– infant or child death
– stillbirth or maternal death
• Policy should include approach to case record reviews and
evidence based methodology used
• From April 2017 – collect and report on a quarterly basis specified
information on deaths

7. 3 levels of scrutiny
• Death Certification
– Natural causes – certified by attending doctor
– Report to HMC where cannot readily certify death
was due to natural causes
– Notes planned reforms to death certification
process, including Medical Examiner scrutiny
• Case record reviews
• Investigation

8. Case record reviews
• As a minimum, where:
– Family / carers have raised a ‘significant’ concern about the care provided
– All inpatient, outpatient and community deaths of patient with a learning disability
and severe mental illness
– Service speciality, diagnosis or treatment group where an ‘alarm’ has been raised
with the provider
– In areas where people are not expected to die
– Learning will inform improvement work, e.g. if work is planned on improving sepsis
care
– A ‘further sample’ of deaths not in identified categories – not necessarily random
but e.g. deaths on a particular weekday
• All additional to existing requirements for reviews, e.g. where person detained under
MHA 1983
• Also – review any case record review of linked inquest and where HMC has issued a
Regulation 28 PFD Report – to examine effectiveness of review process

9. Investigation
• Could arise following case record review – but be
guided by circumstances for investigation in SIF (in
which case do not delay for case record review)
• Some deaths investigated by HMC – encourages good
communication and working relationship
• Reiterates that there should be a review an
investigation of linked inquest and issue of PFD report
• Also may be a need for further investigation and
improvement action if an inquest identifies concerns in
care provided

10. Other points to note…
• CQC will be strengthening its assessments of providers learning from
deaths
• NHSE will develop guidance for bereaved families and carers
• Potential changes to the way complaints involving serious incidents are
handled
• Accountability at Trust Board level – expected to take a systematic
approach and have robust mortality governance processes
• Encourages consistency in reviews and methodologies – which should be
evidence based
• Case record reviews subject to inter-reviewer variation, does not support
comparisons between organisations and ‘should not be used to make
external judgements about the quality of care provided’

11. • Should have a system for implementing learning
• Share with other services across health economy where there would be
patient benefit – including independent health / social care
• Incorporate PFD Report recommendations
• Any findings should be part of, and feed into, robust clinical governance
processes and structures and be considered alongside other information
and data (complaints, clinical audit, mortality data, incident reports) – to
inform wider plans and safety priorities
• Link with National Reporting and Learning System where a ‘patient safety
incident’

12. Bereaved families
• Ensure bereaved family / carers:
– are engaged in investigation process to seek their views and
contribute
– given opportunity to express concerns,
– have a single point of contact,
– are involved in setting terms of reference,
– are informed of outcome and given opportunity to respond
– receive an open, transparent response and are treated with
compassion
• Remember – saying sorry is not an admission of liability

13. Contact us
Mark Barnett – mark.barnett@brownejacobson.com
T: +44 (0)1392 458768 / M: +44 (0)7920 713971
Resources
https://www.england.nhs.uk/wp-content/uploads/2017/03/nqb-national-
guidance-learning-from-deaths.pdf