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​Learning from Deaths

Learning from deaths of people in their care can help NHS providers improve the quality of the care they provide to patients and their families, and identify where they could do more. 

A Care Quality Commission (CQC) review in December 2016, 'Learning, candour and accountability: a review of the way trusts review and investigate the deaths of patients in England' found that some providers were not giving learning from deaths sufficient priority and so were missing valuable opportunities to identify and make improvements in quality of care.

In March 2017, the National Quality Board (NQB) introduced new guidance for NHS providers on how they should learn from the deaths of people in their care. NHS Improvement is now helping trusts to meet the requirements of the new guidance. 

We will publish our data here, with further explanation below:

September 2018​

June 2018

February 2018

January 2018​​​​

Learning from Deaths Data Explained

Dorset County Hospital reviews the cases of all inpatients that have died, and identifies from national thresholds and triggers those patients that require further in-depth reviews, called Structured Judgement Reviews (SJR). This is based on the Learning from Deaths national guidance. ('National Guidance on Learning from Deaths', National Quality Board, March 2017).​

Every three months Dorset County Hospital publishes the numbers of deaths that have occurred and the numbers that have undergone an SJR. The table of these numbers, and this report, are available on the Trust internet for sharing with our partners including Dorset CCG.

http://www.dchft.nhs.uk/about/trust-board/Pages/learning-from-deaths.aspx

Quarter 2 (1 July – 30 Sept 2018)

The total number of adult inpatient deaths for Quarter 2 (July/August/September 2018) was 150. This is the 'Total number of Deaths in Scope' within table 1. This quarter 48 deaths underwent a full SJR. Some of these SJRs related to deaths occurring in Quarter 1 (April/May/June 2018). Overall our teams are conducting significantly more than the recommended numbers of SJRs. The focus going forward is on continually improving the quality rather than quantity of SJRs.​

Themes arising from SJRs:

  • The need to better identify patients for whom ' Do Not Escalate' treatment is appropriate, thereby avoiding patients being subjected to unnecessary and unwanted interventions.

  • The need to better engage families in the mortality review process and learning from deaths, so that they are fully informed throughout the process.

  • To support care homes in meeting the patient and family's wishes and choice in end of life care & place of death, to avoid unnecessary and unwanted admission via the A&E department.

  • Achieving sustained targets for management of sepsis.

Learning Points

Things we said we would doThings we have done so far
Improve our diagnostic codes

Progress continues to be made within our coding team to improve the quality of diagnostic codes although it is expected this could take up to 12 months before we see the impact on our higher than average SHMI (which is currently 1.18 with our aim  to reduce to <1.12) .

 

Triangulate Quality Improvement (QI) data to better assure the Public, DCHFT  Board, Dorset CCG and NHSI that DCHFT delivers safe and high quality care

What our QI data tells us:

Sepsis: Sepsis screening has achieved the standard required in inpatient areas, with improvements also observed in antibiotic administration. There is some further work to do in relation to recording antibiotic administration within 1 hour.

Infection prevention and control standards have been sustained overall.

VTE risk assessments achieving above national target.

ICNARC (Intensive Care national audit & research centre www.icnarc.org) –national data relating to intensive care and predicted risk of death. DCHFT achieves consistently good outcomes. Coding also more accurate in ITU.

Cardiology performance indicators (South Central Primary Percutaneous Coronary Intervention) identify that DCHFT 30 day post PCI survival is above the national average.

National Cardiac Arrest Audit Report 2017/18: DCHFT is recognising, escalating and managing more deteriorating patients than in previous years. Initial survival from cardiac arrest in this Trust remains above the national average  as does survival from cardiac arrest to discharge home

 

Improve junior doctor clerking alongside education for junior doctors on mortality review processes and importance of diagnostic coding

Junior Doctors have implemented a clerking proforma. First round audit results indicate that there has been an improvement in data recording. A re-audit has been recommended to see if these results are sustained.

Education continues (e.g. on ward rounds) to remind doctors of the importance of accurate diagnosis recording to aid coding.

Achieve (KPI) targets in End of Life Care (EoLC) and ensure bi-directional learning between EoLC group and Hospital Mortality Group (HMG)Palliative Care consultant is a member of HMG. Learning from each group is shared.

Engage families in the mortality review process and learning from deaths

 

Bereavement card issued to relatives.

We recognise that we have further work to do and a task group is being set up to explore engagement. Our neighbouring Trusts issue a bereavement questionnaire with good response rates and we are considering how we might adopt this at DCHFT. We are also using the Academic Health Science Network Mortality Toolkit to improve our approach.

Support patients and families in their wishes and choice for end of life care & place of death

 

Liaison with Dorset CCG & LA and to involve Care Homes leads in how we better support EoLC in the Community​





National Learning & LeDeR:

LeDeR Learning into Action bulletins provide some useful and interesting reading to take forward.

http://www.bristol.ac.uk/media-library/sites/sps/leder/WORKINGAspirpneumJulynewsletterfinal2.pdf

Quarter 1 (1 April – 20 June 2018)

The total number of adult in patient deaths for Quarter 1 (1April – 30 June 2018) was 161. This is the Total number of Deaths in Scope within the dashboard. Of these 161 deaths 21 (13%) so far have had a full SJR. This is in line with a nationally expected rate of 10-15%. In addition the divisional teams have conducted a further 9 SJRs relating to deaths from Quarters 3 & 4 of 2017/18.  A backlog of SJRs generally occurs for a number of reasons including medical records availability and hence these numbers were not included within the numbers of completed SJR on Q3 / Q4 dashboard submissions. We are reviewing our reporting process to better capture the work we are doing. Alongside which we are comparing our process to that of other Trusts to try to achieve better clarity and consistency in order to facilitate data interpretation and comparison against national peers. Nationally this work is ongoing as currently there is no set template and method of presenting the information as part of the commitment to publish data.

Dashboard guidance states: The Structured Judgement Review methodology, for use in relation to adult acute inpatient deaths, allows for reviewers to score a death as having a more than 50% chance of having been 'avoidable' when this judgement is made in relation to the care provided by the trust conducting the review. This is the equivalent of a score of 3 or less. Such deaths are subject to further review and scrutiny. The aim is to learn from deaths and continuously improve the quality of care provided to our patients and their families. 1 death in the last quarter (Q4) was identified within this category.

As well as scoring an 'avoidability' judgement the SJR template allows for reviewers to record quality of care during the 6 stages of care including an Overall Assessment of Care score. Our practice is for deaths judged as low scoring (1or 2) for overall care to be considered by the reviewer and / or Hospital Mortality Group members for a further review by way of Root Cause Analysis (RCA) investigation. Low scores across the 6 stages of care and within the overall assessment of care have been found to relate to areas where care could be improved although the care provided would not necessarily have contributed to the death. Examples include communication across teams, documentation and improving End of Life (EoL) Care. Lessons are learnt and shared across teams. Themes emerging are triangulated across the Trust e.g. within Quality Improvement systems, Sepsis and EoL committees.

DCHFT also review RCAs relating to deaths to cross check any with a low score at SJR (for 'avoidability' and overall care scores). Last year we identified 4 of 8 RCAs relating to deaths having a low score at SJR. 1 of these had an 'avoidability' score of 3 (probably avoidable ie more than 50:50). This is the death mentioned above and recorded on the dashboard for last Q4. In addition, 3 had low scores unrelated to 'avoidability' and are included in the total of 4 reported on the Dashboard for last year. Key to note is the areas for improvements in care were not thought to have been contributory to the death.

It is important to note that many of the SJRs have identified excellent care including excellent care planning, communication, early  identification & management of sepsis and quality of EoLC / bereavement care. The aim of all reviews is to continually improve care – hence the national term 'Learning from Deaths'.