Dear Colleague
Re: London Learning Disability Mortality Review Pilot
The Mazars report into mental health and learning disabilities deaths in Southern Health NHS Foundation Trust which was commissioned by NHS England following the death of Connor Sparrowhawk. The report highlighted that only 1% of expected and unexpected deaths of people with Learning Disabilities were investigated over a four year period. The 2010-13 Confidential Inquiry into Premature Deaths of People with Learning Disabilities reported that up to a third of the deaths of people with learning disabilities were from causes of death amenable to good quality healthcare (which could have possibly been addressed by better healthcare provision).
NHS England has commissioned the Healthcare Quality Improvement Partnership (HQIP) and the University of Bristol to undertake the first national programme to review – and ultimately reduce – premature deaths of people with learning disabilities. Commencing in June 2015 for three years the LeDeR Programme has two key overall aims
• To drive improvement in the quality of health and social care service delivery
for people with learning disabilities.
• To help reduce premature mortality and health inequalities in this population
support local areas to review the deaths of people with learning disabilities.
To support the delivery of these aims it requires the development of a review process for the deaths of people with learning disabilities and takes forward the lessons learned in the reviews in order to make improvements to service provision.
Each NHS England Region has been tasked the overseeing of a pilot review process. The pilot will focus on the deaths of adults with learning disability aged 17 -74yrs The work will align with the work of the ‘Child Death Review Process’ which already exists to review deaths of all young people under the age of 18, including those with learning disabilities.
To support the pilot and seek assurance of current system and processes in place NHS England London Region and London ADASS are seeking:
· That all organisations complete the attached self-assessment questionnaire relating to the key findings of the report into Southern Health Care Trust. This is to provide assurance that there are robust processes in place in relation to unexpected deaths of people with learning disabilities within each organisation.
· Organisations to volunteers to take part in the London Learning Disability Mortality Review Pilot.
Further Information regarding the programme and taking part in the pilot can be found. http://www.bristol.ac.uk/sps/leder/about/reviews-of-deaths/
If you have any questions or require support with completing the questionnaire please contact Elaine Ruddy on
Please can the completed questionnaire be returned to by the 8th July 2016. Thank you in advance for your support with this project.
Yours Sincerely,
Jane Clegg
Interim Chief Nurse NHS England (London Region)
Sean Mclaughlin
Corp Director of Housing and Adult Social Services, Islington / ADASS Regional LD Lead
Cc
Safeguarding Adult Board Chairs
Accountable Officers of Clinical commissioning groups
Directors of Adult Social Services
Self-Assessment Questionnaire (Tool developed by Islington SAB)
Please return to by the 8th July
Organisation completing the Questionnaire:Name and Title of person completing the Questionnaire:
Does your organisation wish to take part in the London Learning Disability Mortality Review Pilot? / Yes / No
Nominated contact person if your organisation is taking part in the pilot
Recommendation / Assurance/processes in place / Further action needed
1 / What assurance are you able to give that where there is an unexpected death of a service user within your service that the death is robustly investigated and that the report is of a quality which allows conclusions to be drawn and action to be identified? Discuss the policies and procedures in place and the governance of this
2 / Please comment on the systems in place across health, social care and commissioning to ensure there is a clear framework for investigation.
3 / How satisfied are you that there are systems in place to ensure that the view of family members, friends and carers are properly integrated into any investigation process?
4 / Data collection – discuss thesystems/measures in place for the recording of unexpected deaths. How is this monitored and reported on? Is there a mechanism to monitor themes and trends and to look at what action is needed?
5 / Is there clarity around what constitutes an unexpected death within the relevant policies and procedures? please provide further information
6 / Any further comments