Ashford and St Peter's Hospitals NHS Foundation Trust is committed to a policy of openness and accountability.
We believe that public services should be clear in how they report their operations to the communities they support.
In this section, we shall be adding information and documents regarding the National Guidance on Learning from Deaths.
You can find out more on the NHS England website.
Learning from Mortality Reviews
This report provides details and assurance on the mortality reporting process for Ashford and St Peter’s Hospitals NHS Foundation Trust.
The report gives details on the screening system and progression to a full Structured Judgement Review (SJR), with further analysis on the findings of the SJR and phases of care. The report provides detail on the learning and the plans for sharing of this learning throughout the organisation.
In quarter 3 of 2017/2018 there were 275 adult inpatient deaths across both Trust sites, of these 159 had initial screening completed.
In response to the publication of the Learning from Deaths quality standard 2017 Ashford and St. Peter’s Hospital NHS Foundation Trust has revised the current mortality review process to align with national requirements. The CQC report Duty, Learning and Candour outlined the case for change to build standardisation and uniformity into the mortality process locally and nationally. Greater emphasis should be placed on independent review of all deaths, to promote objectivity and external scrutiny, with improved engagement with bereaved families/carers to ensure learning from deaths enables and informs quality improvements.
Central to the delivery of our quality objectives is being able to demonstrate that we are a learning organisation. Learning from deaths is important to the trust and resonates with our values of putting patients first, including families and carers.
It is important to the trust that when things do not go as planned resulting in poor outcomes for patients, that we can identify those problems early to be able to understand how and why they occurred, so that we may take meaningful action in order to prevent recurrence.
Retrospective case note reviews will help to identify examples where processes can be improved and gain an understanding of the care delivered to those whose death is expected and inevitable to ensure they receive optimal end of life care.
This standardised Trust-wide process integrating mortality reviews into the governance framework will provide greater levels of assurance to the Trust Board and help to ensure that the organisation is using mortality rates and indicators alongside others such as incidents and complaints to monitor the quality of care and share good practice and learning from mistakes. This document sets out how the Trust will learn from deaths that occur which were unexpected. This is in response to the National Guidance on Learning from Deaths (published March 2017).
The policy makes clear the procedure for responding to and learning from patient deaths across the Trust including:
- When and how the death of a patient should be reported.
- How deaths should be reviewed and investigated by the Trust.
- How the organisation should engage with bereaved families and carers.
- How the Trust learns from deaths to improve and inform clinical practice.
This document complements other Trust policies which are also concerned with the reporting, investigating and learning from incidents.