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News and updates from today's Investigation of Deaths in NHS Trusts conference

Melanie Ottewill speaks at today's conferenceMelanie Ottewill speaks at today's conference

Following the chair's introductions, Dr Gerry Morrow Joint Clinical Lead, Regional Mortality Review Project, Patient Safety Collaborative North East and North Cumbria Academic Health Science Network, opens the conference with a session on 'Learning from investigation of deaths review' covering:
• findings and learning from our regional mortality review programme
• implementing the CQC recommendations and new regulations on serious incident investigation at a local level – what we know so far
• developing the principle of Mortality Governance
• sharing information about deaths between providers: challenges and information governance

Dr Morrow comments

‘In the North West we set up a group to investigate all the hospital deaths. We looked at many and tried to analyse the issues’ ‘One of the issues we found was that the documentation was pretty poor’

‘In January 2017 we moved to an online secure system which helps to make it quicker and easier to record accurate documentation’

‘7 trusts in the North East are sharing the same database for recording deaths. Out of 12626 deaths the database found only 0.4% preventable’

‘If there is any data missing, we flag this up to the trusts and encourage them to complete this, so we can make sure the data is accurate’

‘It’s usually within one week, that this information is captured and completed’

Dr Morrow's biography:

Gerry was a full-time GP and senior partner at a small, rural and award winning practice for over 20 years. During that time, he developed an expertise in evidenced-based medicine and patient involvement. For the past five years he has been medical director and editor at Clarity Informatics.

He edits clinical content for Clinical Knowledge Summaries published by the National Institute for Health and Care Excellence (NICE). He has also written clinical content Public Health England. He presents regularly at national and international events on clinical quality improvement methodology and clinical decision support tools.

Presentation Abstract

Monitoring hospital mortality using Retrospective Case Record Review (RCRR) is being adopted throughout the National Health Service in England. A standardised national method for such reviews will be introduced later this year, with mandatory reporting. This presentation describes the experience of reviewing the care records of inpatients who died during or within 30 days of admission to hospital in the North East of England.

Melanie Ottewill National Safety Investigator Healthcare Safety Investigations Branch (HSIB) & Former Head of Clinical Investigations Brighton & Sussex University Hospitals NHS Trust, opens the afternoon with a focus on 'The decision to investigate' covering:

• deciding whether a review or an investigation is needed
• developing consistency in practice
• the role of the Serious Incident Investigation Framework
• an update from HSIB

Melanie comments: ‘At The Healthcare Safety Investigation Branch we make the decision of whether to carry out a review or an investigation’
‘We want to think more creatively about what an investigation might look like’ 
‘Its thinking outside of process’s and how you can be best at responses’
‘From September 2017 all trusts need a policy of how they deal with deaths’
‘The Healthcare Safety Investigation Branch  is an NHS organisation. We became operational on the 1st April 2017. Our aim is to try and improve patient safety’
‘All our investigations are on our website – its all transparent – we want to be trusted’

Melanie's biography:

I am a registered nurse and qualified social worker and have worked in both statutory and non-statutory settings. 
I am currently working as a National Investigator with the newly established Healthcare Safety Investigation Branch. Prior to this post, I worked in Brighton & Sussex University Hospitals NHS Trust (BSUH) for over 20 years in different clinical settings as well as posts such as the Joint Head of Complaints before becoming the Head of Clinical Investigations in 2008. 
I have conducted over 100 Serious Incident Investigations and led on the implementation of Duty of Candour within BSUH. I am passionate about increasing the focus on human behavioural factors in Serious Incident investigations and ensuring meaningful engagement with patients and families who have experienced harm during their care.

Presentation Abstract: 

This session will be highly practical and use different case examples to demonstrate how the decision to investigate might be made. Considering the plethora of recent reports into Serious Incident investigations, alongside the Serious Incident Framework, the session will also share some examples of different ways to investigate deaths that allow for a ‘proportionate and appropriate’ response whilst using scare investigative resource wisely. It is hoped these examples will provoke discussion and differing view-points which can be aired and debated in the question and answer session. The session will also provide an update on the Healthcare Safety Investigation Branch (HSIB) – its role, values, criteria for investigations and those currently in progress.

Key learning:

•    An understanding of reports and documents that should inform the decision to investigate
•    Consideration of some different approaches to use in the investigation of deaths  
•    An example of how to ensure consistency in practice
•    An insight into the work of the Healthcare Safety Investigation Branch

Also of interest:

Hospital at Night Summit: Delivering a 24/7 Hospital
Friday 3 November 2017 
De Vere West One Conference Centre

Reducing Medication Errors National Summit 2017
Friday 3 November 2017 
De Vere West One Conference Centre

2 October 2017


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