Procedure for Reviewing Inpatient Deaths

Procedure for Reviewing Inpatient Deaths

CATEGORY: / Procedure
CLASSIFICATION: / Governance
PURPOSE / To set out the framework for reviewing inpatient deaths across the Trust.
Version Number: / 1.0
Controlled Document Sponsor: / Medical Director
Controlled Document Lead: / Head of Clinical Safety and Governance
Approved By: / Executive Medical Director
On: / 07/11/2017
Review Date: / 07/11/2020
Distribution:

• Essential Reading for:

/ Medical Examiners
Divisional Management Teams
Medical Staff
Safety and Governancestaff

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Procedure for reviewing Inpatient DeathsIssue Date:

Controlled Document Number: 1053Version: 001

1.Introduction

This procedure details the process by which inpatient deaths are reviewed and areas of concern or opportunities for improvingthe quality of care are identified and escalated, when necessary, within Heart of England NHS Foundation Trust (the ‘Trust’).

This procedure does not supersede or interfere with the Trust’s incident investigation process.

2.Procedure

2.1Selection Criteria of Deaths for Stage 1 review

2.1.1All inpatients deaths will receive a Stage 1 review, with the exception of the pre-defined criteria outlined in 2.1.4 below.

2.1.2A Stage 1 review will be undertaken by a Medical Examiner who will make an initial judgement of care and determine whether there are any areas of concern requiring a more in-depth review.

2.1.3The form, which constitutes a Stage 1 review, is available in Appendix A. This form contains the critical elements of the National Mortality Case Record Review Programme (NMCRR) from their structured review tool.

2.1.4Medical Examiners will not complete any review for deaths which fall into the following categories:

a)Forensic deathsor deaths with police interest;

b)Deaths which are subject to urgentCoronial review and/or inquest where the patient’s body and medical records are requested by the Coroner; or

c)Out of area deaths or deaths of patients that fall under the remit of a different Trust or Coroner.

2.1.5Deaths referred routinely to the Coroner that do not have the notes or body requested by the Coroner will still be subject to review by Medical Examiners.

2.2Criteria for aDirectorate Mortality Morbidity (Stage 2)Review

2.2.1For deaths that meet the criteria for escalation (full criteria available in Appendix B) a Stage 2 review will be undertaken.

2.2.2A Stage 2 review requires input from a variety of professionals and will focus on specific aspects of care that were the cause for concern. The forum for this review will normally be a Directorate Mortality & Morbidity (M&M) meeting.

2.2.3Deaths that will be escalatedby the Medical Examiner for Stage 2 review by the Directorate include, but are not limited to:

a)Deaths where care is scored as a 1 or 2 out of 5 on the NMCRR scale by the Medical Examiner;

b)Avoidabledeaths 1-3 based on the NMCRRavoidability scale;

c)If patient’s deathwas considered unlikely based on the patient’s presenting condition;

d)Deaths involving drug errors;

e)Deaths which were a result of a fall or other significantharm incident that occurred as an inpatient.

f)Deathswherefamily, carers or staff have raised concerns about the quality of care provided

2.2.4Whilstall these deaths require review, Directorates are not precluded from reviewing or discussing any other deaths or cases for any other reasons including educational value, national audit requirements or clinical interest at Directorate MortalityMorbidity meetings. Where Directorates have a very high number of deaths e.g. elderly care, a ‘filtering’ review can be undertaken to exclude deaths that were clearly unavoidable and had no associated quality of care issues

2.2.5Other deaths may also be required to undergoa Stage2 review on an ad hoc or ongoing basis according to Trust priorities and focus on specific areas of care

2.2.6All elective surgical deaths

2.2.7All deaths of patients identified with severe mental illness

2.2.8Deaths associated with a mortality outlier alert

2.2.9Review of deaths where, at inquest,a Regulation 28 Report to Prevent Future Deaths is issued to the Trust or where neglect is identified, unless this has been the subject of a Serious Incident Investigation

2.3Final Decision, Further Reviews or Investigations

2.3.1The outcomes of all deaths that are subject to theStage 2 review will be taken to the Trust’s Clinical Quality Monitoring Group (CQMG).

2.3.2A decision will be made as to whether cases require further review or investigation, particularly in cases where the Stage 1 and 2 reviews may have arrived at different conclusions, at CQMG.

2.3.3Those cases that are not felt to require further review willbe signed off by CQMG as such.

2.3.4The outcome of the CQMG decision and stage 2 reviews will be fedback to the Directorates and Medical Examiners by the Medical Directorate Services Team.

2.4Patients withlearning disabilities

2.4.1All patients identified by the Medical Examiner as having learning disabilities will be required to undergo a Stage2 review in line with the National Learning Disabilities Mortality Review (LeDeR) Programme.

2.4.2The identification of a patient with learning disabilities may not always be obvious to the Medical Examiner due toa number of factors, including lack of a formal diagnosis, appropriate communication of a patient’s diagnosis and documentation, where the patient is known to have a Learning Disability according to flags on the electronic patient record.

2.4.3Learning Disability Specialist Nurses will assist the Medical Examiner to identify patients with a Learning Disability by informing the Medical Examiners when a patient with a learning disability dies under the care of the Trust.

2.5Maternity & Paediatric Criteria

All maternity and paediatric cases will undergo an initial stage 1 review by the specialist Medical Examiner or attending clinician and a formal Stage 2 review will be undertaken by their respective Directorates as part of their normal mortality and morbidity review programme. In addition this may require liaising with, and contributing to, external mortality review programmes such as:

2.5.1Data on maternal deaths are reported directly to MBRRACE-UK (Mothers and Babies: Reducing Risk through Audits and Confidential Enquiries across the UK)

2.5.2The Divisional management team for children’s services is responsible for ensuring that all deaths of a child or young person under 18 years (including neonatal deaths) are reported to the Safeguarding Children’s Team

2.5.3All relevant neonatal deaths are reported to the neonatal subgroup of the Child Death Overview Panel (CDOP). All unexpected deaths or deaths with an identified, or potential, quality of care issue are escalated to the full CDOP. Reports are made to CDOP direct, in accordance with their protocols.

2.5.4Sudden Unexpected Death in Childhood.

The death of a child (less than 18 years old) that was not anticipated as a significant possibility 24 hours before the death; or where there was an unexpected collapse or incident leading to, or precipitating, the events that lead to the death. The SUDIC process is a multi-agency response to unexpected child deaths and forms part of the statutory Child Death Overview Process which is led by Local Safeguarding Children Board (LSCB)

2.6Overlap with Incident Management processes

2.6.1In the course of identifying areas of concern it is anticipated that there will be occasions where concerns raised by Medical Examiners have already been raised as part of the Trust’sincident management process.

2.6.2The Trust incident management process will operate independently of thisprocedure but, as part of some incident investigations, the findings of Stage 1 and Stage 2 reviews may be considered.

2.6.3Similarly, cases may be identified which are felt to warrant independent and formal investigation as part of the Trust’s Serious Incident process; this decision will be made by the Executive Medical Director.

2.7Involvement of Bereaved Families and Carers

2.7.1The Bereavement Servicewill continue to be actively involved with the families and carers of bereaved families. Further details can be found in the associated Bereavement Care Services Policy and Procedures

2.7.2The Medical Examiners will make contact, where possible, with all relatives or next of kin when they are providingthe Medical Certificate Cause of Death (MCCD) and will escalate any concerns identified. Feedback to the relatives will be coordinated by the Bereavement service and PALS, if required

2.7.3For any deaths where the outcome requires aserious incident investigation, the clinicalinvestigation team will contact the family or carers after the initial Duty Of Candour conversation has been carried out by the responsible clinical team and offer them the opportunity to meet and discuss their concerns or any questions they might have. Further guidance can be found in the associated Incident Reporting and Management Policy and Procedure.

3.Reporting to Trust Board

The Safety and Governance Directorate will provide a quarterly summary report, using the national dashboard template, to CQMG and then the Trust Board which will include actions and learning from the reviews.

4.References

National Mortality Case Record Review

National Quality Board: National Guidance on Learning from Deaths

5.Associated Policy and Procedural Documentation

Bereavement Policy and Procedures

Incident Reporting and Management Policy and Procedure

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Procedure for Reviewing Inpatient DeathsVersion: 1.0

Appendix A: ME Stage 1 review form

Category / Questions / Answer
Death Expected / Was this Death Expected / Expected
Highly Likely
Death was a Possibility
Death was Unlikely
Very Unlikely
Medical Response / Appropriate management for the diagnosed condition / Yes
No
Was the patient under the care of an appropriate specialty / Yes
No
Was the patient on an appropriate ward / Yes
No
Drugs / Did any drug errors contribute to death? / Yes
No
Falls and Untoward Incidents / Were there any falls or significant incidents of harm? / Yes
No
Did they significantly contribute to death / Yes
No
Has there been any complaints/conflict documented? / Yes
No
Is there evidence of communication with complainee to resolve issue? / Yes
No
Operative Procedures / Were there any unpredictable complications / Yes
No
N/A
ICU/HDU / Any delay in getting ICU Opinion (Expectation is that a review occurs within 60 minutes) / Yes
No
Not Needed
Was a bed available in a timely manner / Yes
No
End of Life Plan / Was there a holistic end of life care plan in place in the final 24 hours of life? / Yes
No
Summary / Overall during the patient’s episode, is there a recognisable medical plan of care / Yes
No
On balance, might this death reasonably have been prevented / Yes
Possibly
No
RCP Methodology Avoidability Score / RCP Methodology Avoidability Score / Score 6 – Definitely not avoidable
Score 5 – Slight evidence of avoidability
Score 4 – Possibly avoidable but not very likely
Score 3 – Probably avoidable (more than 50:50)
Score 2 – Strong evidence of avoidability
Score 1 – Definitely avoidable
Summary of Patient Care / Summary category of the patient’s care / 5 - Excellent care: This was excellent care with no areas of concern.
4 - Good care: This was good care with only one or two minor areas of concern and no potential for harm to the patient
3 - Adequate care: This was satisfactory care with two or more minor areas of concern, but no potential for harm to the patient
2 – Poor Care: Care was suboptimal with one or more significant areas of concern, but there was no potential for harm to the patient
1 – Unsatisfactory care: Care was suboptimal in one or more significant areas resulting in the potential for, or actual, adverse impact on the patient.
Summary of Patient Care / Summary category of the patient’s care / Score 1-6
Comments / Comments about care / Free text
Irrespective of score, indicate whether you believe this case should be reviewed further by the relevant clinical specialty / Yes
No

Appendix B: Escalation Criteria

Criteria:

1. Death classified as “Unlikely” or “Very Unlikely”

1. Answer of “Yes” for “Did Drug Errors lead to death”

1. Answer of “Yes” for “Did they significantly contribute to death” with regards to any significant incidents or falls relating to patient

1. Answer of “Yes/Y” for “Might this death reasonably have been prevented”

1. Score of 1 or 2 on summary category of patient care

1. Score of 1, 2 or 3 on RCP avoidability scale

1. Elective surgical deaths

Learning disabilities or severe mental health

9.1Appendix C: Process Flowchart

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Procedure for Reviewing Inpatient DeathsVersion: 1.0