In March 2017, the National Quality Board (NQB) published national guidance on Learning from Deaths: A Framework for NHS Trust and NHS Foundation Trusts on Identifying, Reporting, Investigating and Learning from Deaths in Care.
The guidance provide requirements Trusts need to implement as a minimum in order ensure there is a focused approach towards responding to and learning from deaths of patients in our care.
The main purpose of this policy and the content is to promote learning and improve how the Trust support and engage with the families and carers of those who die in our care; it is not in place to purely count and classify deaths.
The Trust strives to improve the care provided to all of our patients; the overall aim is to identify, understand and implement improvements where any issues are related to the provision of quality care. It is considered that if such improvements are initiated effectively and embedded, then the mortality statistics will naturally show improvement.
Our Trust policy provides details on how the organisation will ensure compliance with the requirements set out in the NQB guidance (2017). The policy sets out the process by which the Trust will:
- Identify and investigate deaths in care.
- Ascertain learning points to ensure these are used to support changes in practice.
- Provide support for bereaved families and offer them the opportunity to highlight any concerns they may have and to request a mortality review be completed.
- Support staff in collecting and using information to initiate quality service improvements and demonstrate learning.
- Describe how the Trust will report details in relation to completed mortality reviews and also the learning obtained through this work.
For many people death under the care of the NHS is an inevitable outcome and they experience excellent care from the NHS in the months or years leading up to their death. However, some patients experience poor quality provision resulting from multiple contributory factors, which often include poor leadership and system-wide failures. NHS staff work tirelessly under increasing pressures to deliver safe, high quality healthcare. When mistakes happen, providers working with their partners need to do more to understand the causes.
The purpose of reviews and investigations of deaths, which problems in care might have contributed to, is to learn in order to prevent recurrence. investigations are only useful for learning purposes if their findings are shared and acted upon.
The full learning from deaths policy can be found in our online document resource centre.