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Reducing & Monitoring Avoidable Hospital Deaths attributable to problems in care

Thursday 8 October 2015
Hallam Conference Centre, London

Reducing & Monitoring Avoidable Hospital Deaths attributable to problems in care

This event has now past, but there may well be news on the event including presentations and quotes from the day at our News pages here, a full list of our forthcoming events is available here.

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“Next March we will go further still, becoming the first country in the world to publish avoidable deaths by hospital trust” Jeremy Hunt, Minister of State for Health, 16 July 2015

“I want all hospital boards to have a laser-like focus on eradicating avoidable deaths in their organisation; even one life lost to poor care or safety error is too many” Jeremy Hunt, Minister of State for Health, 8th February 2015

Prof Nick Black, at the School of Hygiene and Tropical Medicine has been leading a national review of mortality commissioned by Sir Bruce as part of the recommendations set out in the Keogh review. The original review, carried out by Sir Bruce Keogh, was published last year and looked at the quality of care and treatment at 14 hospital trusts in England. The hospital trusts were selected for the Keogh review based on either the Hospital Standardised Mortality Ratio (HMSR) or the Summary Hospital-Level Mortality Index (SHMI), which were used to flag up hospitals where apparently unusually high numbers of patients are dying. In the review. Sir Bruce set out eight ‘ambitions’ for improvement to tackle some of the underlying causes of poor care. 

Prof Nick Black recently spoke about why hospital-wide mortality ratios should be avoided and what should replace them. This conference focus on the question of mortality monitoring: where are we now? Through national updates and practical case studies the conference will look at how we can reduce and monitor avoidable deaths in hospitals through a range of measures which will replace the single hospital wide HSMR approach. The various approaches will aim to answer the question of whether a problem in care contributed to death, and how to identify which deaths attributable to problems in care are unavoidable. Areas covered will include mortality audits, internal inspection, mortality reviews, case note reviews, early identification of care problems, the patient voice as an early warning system and the role of mortality monitoring for individual consultants.

“I don’t set much store by these hospital standardised mortality ratios. The good news is that we must still look at mortality and there is another way of doing it and that is to do case note reviews, by which I mean we look in great depth at each and every death in a hospital; we get clinicians, physicians to do this who have been specially trained, using all the standardised techniques, and from that we can determine what proportion of deaths are avoidable. It’s a time consuming process but there’s immediate benefits to the clinicians because they learn things about their own hospital and their own care.” Prof Nick Black, Lead, Study into Avoidable Deaths, & Professor of Health Services Research, London School of Hygiene and Tropical Medicine

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