Regional Mortality Review Project

As a result of our approach, we now have data in a unified database for three years relating to over 9500 in-patient deaths in four acute trusts in the North East of England. This equates to an average of 54% of all in-hospital deaths. The reviews were conducted at each trust and quantitative scoring determined across two nationally accepted standardised parameters for were applied each death. The approach of using a unified database and standardised data collection has enabled a consistent approach to understanding deaths per trust, data analysis and the possibility of shared learning across a region.

Results

The overwhelming majority of all deaths reviewed were categorised as having had ‘good’ care and were ‘definitely not’ preventable. There were a small number of deaths (range 0.1-0.8%, average 0.5%) in this cohort which have been identified as having’ room for improvement’ in care and a ‘greater than 50% chance of being preventable’. If we extrapolate this finding it equates to 1143 in-hospital deaths across NHS England, which could potentially be described as ‘avoidable’.

Next steps

We believe that this regional unified approach delivers a pragmatic platform to learn from in-hospital deaths. In addition, as all trusts seek to implement the recommendations of the Care Quality Commission report ‘Learning, candour and accountability’ our approach allows providers to learn from our experience.

Our data collection approach has now incorporated eight specialist team bespoke reviews including care of the elderly, cardiothoracic surgery and orthopaedics. This has allowed trusts the ability to step-up and step-down mortality reviews across their teams. This method has provided trusts to disseminate thematic learning from patient deaths in order to inform future clinical care.

We also believe that this approach will provide a flexible platform for the incorporation of assessments from Medical Examiners and General Practice, which are likely to be part of the future direction of mortality review.

Resources

Mortality Review Case Study 2017

Mortality review videos and resources 

BMJ Open quality publication: From research to practice: results of 7300 mortality retrospective case record reviews in four acute hospitals in the North-East of England

 

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