Hospitals learning from deaths to improve care

A new Royal College of Physicians (RCP) report has revealed that hospitals are using a standardised review approach to learn from adult acute deaths and improve patient care.

Learning from deaths, published in 2017, mandated all English trusts to conduct mortality reviews. The RCP's National Mortality Case Record Review (NMCRR) has developed the structured judgement review (SJR) process to effectively review care received by patients who have died, with the 2018 annual report citing a number of case studies where the SJR has made positive contributions to improving healthcare for patients.

The report highlights how Buckinghamshire Healthcare NHS Trust introduced medical examiners and the SJR process to screen all deaths in 2017. Within just six months, 97 per cent of deaths were screened and 12 per cent of all cases used the SJR process.

The NMCRR team has trained around 480 healthcare professionals across England and Scotland, who in turn have shared their training with at least 1,500 other healthcare professionals including doctors and nurses since the NMCRR was implemented in 2016.

Andrew Gibson, consultant neurologist and clinical lead for the NMCRR, said: “This pioneering NMCRR programme aims to implement a validated, standardised way of reviewing the case records of adults who died in hospitals across England and Scotland. The report demonstrates that through using a standardised review approach NHS trusts can successfully improve quality in patient care and safety. It also highlights the significant efforts required to implement the programme nationally and the enthusiasm from those involved to work collaboratively.”

David Oliver, RCP clinical vice president, said: “Nearly half of deaths in the UK happen in hospital and quite rightly there has been growing political and professional focus in recent years on improving end-of-life care, support for the bereaved, and learning from and ultimately eliminating preventable deaths. It is therefore really positive to see that the use of our SJR validated, structured tool is already contributing to positive changes.

“So far we have trained 450 reviewers to use the SJR approach who are supporting hospitals to identify good practice and areas for improvement and develop stronger cultures of openness, learning and partnerships with families. There is still much to do, and our advice is that mortality reviews and other quality improvement initiatives should be fully embedded across all NHS trusts.”