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Investigation of Deaths in NHS Trusts: Implementing the CQC Recommendations

Chaired by Dr Martin Farrier Clinical Director for Quality & Consultant Paediatrician Wrightington, Wigan and Leigh NHS Foundation Trust, this one day CPD certified conference will demonstrate how you can effectively implement the CQC recommendations in practice.

Mr Tony Roberts Deputy Director (Clinical Effectiveness) South Tees Hospitals NHS Foundation Trust Patient Safety Collaborative Lead for North East and North Cumbria AHSN opens the conference with an update on 'Learning from investigation of deaths review' and will discuss:

  • findings and learning from our regional mortality review programme 
  • overview of the CQC review into investigations of deaths in NHS Trusts and the new regulations for Trusts to estimate avoidable deaths 
  • implementing the CQC recommendations and new regulations on serious incident investigation at a local level – what we know so far

In his presentation Tony stated:

“Provider organistions and commissioners all need to change the way we look at deaths”

“NQB was tasked with producing guidance which was first published in march”

From April 2017 the NQB national guidance on learning form deaths require

  • Acute, mental health and community NHS Trusts and Foundation Trusts should ensure their governance arrangements and processes include, facilitate and give due focus to the review, investigation and reporting of deaths, including those deaths that are determined more likely than not to have resulted from problems in care. Trusts should also ensure that they share and act upon any learning derived from these processes.
  • Non Executive Director and Executive Director Board responsibility
  • Enhance skills and training
  • A clear policy for engagement with bereaved families and carers
  • Each Trust should publish an updated policy by September 2017 on how it responds to, and learns from, deaths of patients who die under its management and care.

“It is feasible to carry out large numbers of case record reviews and to link them locally to other governance processes including investigations of Serious Incidents.”

“Case record review estimates of rates of avoidable death are subject to ‘denominator’ effects. Internal reviewers, in our experience, report lower rates of preventable mortality than the published literature.”

“Sharing information about deaths between providers means solving important IG issues. There are technical issues to overcome – but the NHS Number could be used. Ideally we would use one system across a region.”

“If Medical Examiners are introduced across England by April 2019 we will need to be open to the major advantages that will bring to involve families in a timely manner.”

Full powerpoint presentation available here

Pre conference abstract:

The National Quality Board published in March 2017 Guidance on Learning from Deaths[1], and a suggested Dashboard[2], for publication of information on avoidable deaths on a quarterly basis in 2017/18 by all NHS trusts and Foundation Trusts. The guidance comes in response to the CQC’s report Learning, Candour and Accountability[3], published in December 2016.

The guidance requires each Trust to publish an updated policy by September 2017 on how it responds to, and learns from, deaths of patients who die under its management and care. There are three levels of scrutiny that a provider can apply to the care provided to someone who dies; (i) death certification; (ii) case record review; and (iii) investigation. The policy should set out how the trust manages each of these steps.

The North East and North Cumbria have considerable experience in the acute hospitals in reviewing deaths and a summary of several projects involving thousands of reviews show that the estimate of preventable deaths is very much lower than in the published research. However around a fifth of reviews identified room for improvement in the quality of care.

“Mortality reviews are a valuable approach to improving the safety and quality of care, although using them to estimating rates of preventable deaths will continue to be controversial. In order to meet the requirements set out by the National Quality Board most trusts will need to strengthen arrangements for case record review and the link to investigations. Our experience suggests that this will require innovation, particularly by using web based technology to facilitate the process. The first step towards better sharing of information about deaths, reviews and investigations across the healthcare system will be to address the important Information Governance issues involved. Much of the work will be achieved more easily at a regional level.”


[1] https://www.england.nhs.uk/wp-content/uploads/2017/03/nqb-national-guidance-learning-from-deaths.pdf

[2] https://www.england.nhs.uk/wp-content/uploads/2017/03/nqb-learning-from-deaths-dashboard.xlsx

Tony Roberts Biography:

Tony is an NHS measurement specialist, with experience in hospital, primary care and general practice settings. His background is in Health Services Research, epidemiology and Statistical Process Control. He works for South Tees Hospitals NHS Foundation Trust where he is Deputy Director (Clinical Effectiveness). He is seconded part-time as Deputy Director of the North East Quality Observatory Service (NEQOS) where he has a particular interest in hospital mortality and monitoring of clinical outcomes more generally. As part of his work for NEQOS, he is the Patient Safety Collaborative Interim Programme Lead to the AHSN North East & North Cumbria where he focuses on using measurement to improve quality of care and patient safety across the healthcare system. His recent work has been in high risk patients with time-sensitive conditions like sepsis, community acquired pneumonia and acute kidney injury. Tony is a member of the Q Initiative.

The morning sessions continue with a presentation from Alison Unsworth Divisional Clinical Coding Lead Medicine Wrightington, Wigan and Leigh NHS Foundation Trust on 'Clinical Coding: What is it?' 

In her presentation Alison commented:

'Clinical Coding is the translation of medical terminology that describes a patient’s complaint, problem, diagnosis, treatment or other reason for seeking medical attention into codes that can then easily be tabulated, aggregated and sorted for statistical analysis in an efficient and meaningful manner’

What do we do?

  • Read the whole of the episode
  • All relevant letters
  • Lab reports
  • We can only code from what is documented
  • We can’t interpret results
  • We have national standards to adhere to…

Full powerpoint presentation available here

Alison's Unworth's Biography:

Alison has worked in the NHS for 27 years, spending 20 years as a Clinical Coder at Wrightington, Wigan and Leigh NHS Foundation Trust.  Over the last 5 years, she has been working as the Divisional Clinical Coding lead for the Medical division,  establishing links with clinical staff and management and driving forward clinical involvement in the whole coding process.  She has worked very closely with the Associate Medical Director in implementing a mortality audit, using data to identify focus areas to create quality improvement and generate change.

Outside of work, she is married with two teenagers.  She enjoys walking, horse riding, watching her children in their sporting activities, spending time with family and friends and is a volunteer with the Girl Guides Association.

Future conferences of interest:

Deteriorating Patient Summit
Monday 15 May 
De Vere West One Conference Centre, London

Hospital at Night Summit: Improving Out of Hours Care in Hospitals
Friday 9 June 
De Vere West One Conference Centre, London


8 May 2017

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