/Policies and guidelines/Mortality review and responding to deaths policy

Mortality review and responding to deaths policy

Document control

Policy owner: Deputy medical director and CCIO
Corporate lead: Executive medical director
Document version: V6
Document status: Final
Date approved by Clinical and Corporate Policies Group (CCPG): 21 October 2020
Date ratified by SMT: 6 January 2021
Date issued: 8 January 2021 (updated April 2023)
Next review date: January 2024
Policy number: PL368

Executive summary

This policy explains the procedures to be followed within Leeds Community Healthcare NHS Trust (LCH) services in relation to mortality review and responding to deaths. This applies to all services within LCH and includes the specific processes to be followed in each business unit. The policy is based on guidance from the National Quality Board (2017) around how trusts should investigate and learn from deaths. This should always include engaging with relatives to ensure all relevant aspects of care and delivery are investigated based on relatives experience as well as that of the trust.

Equality analysis

Leeds Community Healthcare NHS Trust’s vision is to provide the best possible care to every community. In support of the vision, with due regard to the Equality Act 2010 General Duty aims, Equality Analysis has been undertaken on this policy and any outcomes have been considered in the development of this policy.

Table of content

Introduction
Aims and objectives
Definitions
Responsibilities
Mortality review and responding to deaths process
Risk assessments
Training needs
Monitoring compliance and effectiveness
Approval and ratification process
Dissemination and implementation
Review arrangements
Associated documents
References
Appendices

1. Introduction

Death is one of, if not, the most significant event in a person’s life and broadly falls into one of two sets of circumstances:

Expected
Unexpected

Mortality reviews are a key part of showing effective and safe patient care.

Whilst mortality reviews have traditionally been held within acute NHS organisations, they have not been routinely held in NHS organisations outside of an acute trust, including NHS services delivered in the community. The Francis Report (2013) describes the process of mortality reviews as a key part of reviewing patient outcomes and working towards a high-quality service. It is expected by NHS Improvement and the Care Quality Commission (CQC) that NHS organisations have these processes in place.

The National Quality Board has issued National Guidance on Learning from Deaths and has said that for many people death under the care of the NHS is an inevitable outcome and they experience excellent care from the NHS in the months and years leading up to their death. However, some patients experience inferior quality provision, resulting from multiple contributory factors, which often include poor leadership and system-wide failures. Therefore, it is essential that we learn from deaths whereby systems or leadership issues have been a contributory factor, to prevent recurrence. Reviews and investigations are only useful for learning purposes if their findings are shared and acted upon. This includes sharing learning with other providers.

2. Aims and objectives

The aim of this policy is to describe the framework for reviewing all cases of expected and unexpected death.

The objectives are to:

ensure that all incidents of mortality where the patient was under the care of Leeds Community Healthcare NHS Trust (LCH) services are appropriately reviewed
outline the process for notifying acute providers of all patient deaths occurring within 30 days of discharge from any acute hospital setting
review the quality of care at or near the time of death to identify any lapses or omissions in care, ensure patient safety and the provision of high-quality care
ensure that, where required, actions are taken and learning shared to improve the safety and quality of patient care
ensure that processes are clear relating to being open and transparent in line with our PL245 Being Open Policy and Duty of Candour Policy to disclose incidents and poor care practices, including lapses or omissions in care, to commissioners, service users and (or) relatives
involve service users and (or) relatives in mortality investigations
Collect data to benchmark incidents of mortality with similar NHS organisations to evaluate if LCH incidents of mortality are in keeping with comparable services.

3. Definitions

Expected death is the result of an acute or gradual deterioration in a patient’s health status, usually due to an advanced progressive incurable disease. The death is anticipated, expected and predicted.

Unexpected death is a death that is not anticipated or related to a period of illness that has been identified as terminal (Hospice UK, 2020a).

Sudden unexpected death in childhood (SUDIC): A death that was not anticipated as a significant possibility 24 hours before, or where there has been a seemingly unexpected collapse, leading to or precipitating the events that led to death.

Child death overview panel (CDOP): A multi-agency panel set up by Public Health and includes representatives from child death Revie partners to review the deaths of all children (up to their 18th birthday) normally resident in their area, in order to learn lessons and share any findings for the prevention of future deaths.

(Working Together to Safeguard Children. HM Government, 2018)

Learning Disabilities Mortality Review Programme (LeDeR) set up as a service improvement programme to look at why people with Learning Disability are dying and what can be done to change services locally and nationally to improve the health of people with a learning disability and reduce health inequalities.

Serious mental illness (SMI) refers to people with psychological problems that are often so debilitating that their ability to engage in functional and occupational activities is severely impaired. Schizophrenia and bipolar disorder are often referred to as an SMI.

4. Responsibilities

4.1 Chief executive

The chief executive has ultimate responsibility for ensuring that the trust has robust policies and procedures in place for reviewing all incidents of mortality.

4.2 Executive medical director

The medical director is responsible for ensuring that there is a comprehensive mortality and responding to deaths policy, ensuring that all incidents of mortality are appropriately reviewed and where required appropriate actions are taken and learning disseminated.

4.3 Business unit clinical leads

Are responsible for:

ensuring there are arrangements for reviewing all incidents of patient mortality within their business unit
ensuring that each business unit has a Mortality Review Group and mortality review meeting to oversee the management of all mortality reviews
producing a quarterly thematic mortality review report.

4.4 Clinical pathway lead (Adult business unit), Clinical head of service (Specialist business unit), Service manager (Children’s business unit)

Are responsible for ensuring that all staff are aware of this policy and support its implementation within their service(s).

4.5 Clinical staff in all business units

All LCH staff are responsible for ensuring that when a death occurs, they follow their business unit’s mortality reporting process, unless the service is excluded from this process (as determined by the Business Unit’s local process), or if the death was an expected end of life pathway death and the patient was included on the Electronic Palliative Care Coordination System (EPaCCs) with ‘on Gold Standard Framework (GSF) for palliative care’ recorded.

The service reporting the death also needs to inform any other services providing care to the patient that they have reported it, in order to prevent duplicate reporting. They are also responsible for ensuring that they follow their business unit’s procedure for escalation in response to reporting of deaths.

There is also a requirement to notify acute providers of all patient deaths occurring within 30 days of discharge from any acute hospital setting.

4.6 Mortality review meeting

The members of the mortality review meeting in each business unit are responsible for:

attending monthly mortality review meetings (bi-monthly in the children’s business unit in order to align with the citywide review meetings)
supporting the completion of all in-depth reviews
discussing concerns raised by the case reviews
identifying and feeding back learning and action points
when considered appropriate, escalating learning and actions points to the Quality, Assurance and Improvement Group.

All staff employed by Leeds Community Healthcare NHS Trust must work in concordance with the Leeds safeguarding multi-agency policies and Procedures and local guidelines in relation to any safeguarding concerns they have for service users and the public with whom they are in contact.

5. Mortality review and responding to deaths process

5.1 Reporting

All deaths that occur whilst a patient is under the care of LCH services and on an active caseload both expected and unexpected will be reported via their Business Unit’s mortality reporting process. The only exceptions to this will be:

if the patient is included in EPaCCs with ‘on GSF for palliative care,’ or
if the death occurs whilst a patient is under the care of a service that is excluded from this process and as identified in the local process for that business unit (refer to local processes in appendices 3, 4, 5 for exceptions), or
if a person has been admitted to a non-LCH hospital for more than 24 hours at the point of death.

It is also a requirement to notify acute providers of all patient deaths occurring within 30 days of discharge from any acute hospital setting.

Any death that is associated with known harm will be reported, in addition, to the trust incident reporting system via Datix®. This can be at any stage including at death or via the business unit’s reporting process.

5.2 Completing a mortality review

All deaths where a patient is on an active caseload across LCH services will be subject to a review as per the local process as defined above. This will include all patient deaths reported on Datix®, on EPaCCs or reported via the SUDIC process.

The mortality review process will be a two-level process for the adult and specialist business units:

All deaths, both expected and unexpected, will be reviewed via the level 1 mortality assessment tool (appendix 1). This will determine whether a more in-depth review is required, including possible reporting as an incident via Datix®.
If indicated by the outcome of the level 1 mortality assessment tool, further investigation using level 2 mortality review tool must be undertaken (appendix 2).

Both tools are accessible as a questionnaire on SystmOne and are available in other formats for those areas that do not use SystmOne.

The children’s business unit will use the process as defined in appendix 4.

The level 1 mortality assessment tool should be completed following the individual business unit guidance (appendices 3 and 5). The case manager, care coordinator or caseload holder will support this with oversight from the neighbourhood or unit clinical quality lead or clinical service lead in the team or service as per each business unit’s process.

Every death reported on Datix® will be specialist reviewed by the clinical lead, head of service or quality lead (according to local Business Unit guidance) to ensure the correct process is instigated in terms of the two-stage mortality review process outlined in 5.2.2.

Each business unit will ensure that they follow the mortality reporting and review flowchart for their business unit:

Adult business unit mortality review process (appendix 3)
Children’s business unit mortality review process (appendix 4)
Specialist business unit mortality review process (appendix 5).

At the point of completing a mortality review tool, it will be identified if the patient is under a number of services within LCH. Where this is the case, all services should participate and contribute to the review. The ‘lead’ for the review will be the most appropriate service (for example, the service with the most involvement or with the most appropriate clinical expertise).

5.3 Relative involvement, Duty of Candour and serious investigations

All services must ensure that where a death has occurred, the relatives are aware that a mortality review will take place as part of our standard processes and are given the opportunity to participate in the review. This conversation should take place as part of the bereavement support discussions.

Relatives can expect the key principles will be followed as outlined in Learning from deaths: Guidance for NHS trusts on working with bereaved families and carers (National Quality Board, 2018).

Bereaved families and carers should be treated as equal partners following a bereavement.
Bereaved families and carers must always receive a clear, honest, compassionate and sensitive response in a sympathetic environment.
Bereaved families and carers should receive a high standard of bereavement care which respects confidentiality, values, culture, and beliefs, including being offered appropriate support. This includes providing, offering, or directing people to specialist suicide bereavement support.
Bereaved families and carers should be informed of their right to raise concerns about the quality of care provided to their loved one.
Bereaved families and carers views should help to inform decisions whether a review or investigation is needed.
Bereaved families and carers should receive prompt, responsive contact and support in all aspects of an investigation process, with a single point of contact and liaison.
Bereaved families and carers should be partners in an investigation to the extent, and at whichever stages, that they wish to be involved, as they offer a unique and equally valid source of information and evidence that can better inform investigators.
Bereaved families and carers who have experienced the investigation process should be supported to work in partnership with the trust in delivering training for staff in supporting family and carer involvement where they want to.

All services must ensure that where a death has occurred, and lapses or omissions in care have been identified that may have contributed to the death, that the Duty of Candour process is enacted in accordance with the PL245 Being open policy and Duty of Candour policy, with the use of an interpreter or advocate where appropriate.

Some deaths may fall into the category of a Serious Incident (SI), for example, a death in police custody. Where this is the case the SI process will be the process used to investigate the death.

5.4 Additional considerations and requirements

Where the death of a patient with a Learning Disability (LD) has occurred under the care of the Trust services this will need to be indicated on the relevant sections of the reporting forms. The death will also be reported via the Learning Disabilities Mortality Review Programme (LeDeR) by the service involved and will be subject to a CCG appointed independent review process which will contribute to the internal LCH review process. The review will be independently reviewed in addition by one of the LeDeR reviewers across the city to check there were no additional considerations or learning that had not previously been identified. All LD cases will be reported, specifically in the quarterly data.

Where the death of a patient with a Serious Mental Illness (SMI) has occurred whilst under the care of the Trust’s services the death will need to be indicated on the relevant sections of the reporting forms. All SMI cases are to be reported, specifically in the quarterly data. The exception to this is a patient with dementia which for the purposes of this policy will not class as a SMI.

Where an expected death has occurred without a registered EPaCCs, consideration will be given to the possible opportunities for there to have been a supportive planning ahead or advanced care planning discussion.

The Children’s Business Unit has a separate palliative care system to EPaCCS.

Where the unexpected death is a child, the death will be reported via the Sudden Unexpected Death in Infants and Children (SUDIC) route and follow that process.

An expected death in a child who has been under the care of an LCH service in the past 6 months will be reported via the process for expected death in a child.

If considered appropriate to the individual case:

Relatives are signposted to a source of support, for example, counselling, charities
Staff are offered a 1 to 1 with their line manager and signposted to support sources, for example, such as in the case of SUDICs.

5.5 Learning from deaths

The trust’s mortality review process will ensure that where a death has occurred, if there are omissions or lapses in care from LCH services that the learning is identified and shared appropriately, in accordance with the PL245 Being Open Policy and Duty of Candour Policy. Examples of good practice/care will also be identified and shared. Learning will contribute and drive changes to policy and guidance. It will also ensure that acute providers are informed of deaths occurring within 30 days of hospital discharge, giving an opportunity for learning via their local mortality review processes.

All deaths that are specialist reviewed at a level 2 mortality review will be considered for the local mortality review meeting. Where the learning goes beyond the local level (for example, variations in quarterly trends, possible adverse trends) this should be escalated for discussion at the organisations Mortality Surveillance Group (QAIG).

Learning will be shared across the organisation as required and utilising a variety of methods, for example, learning events, workshops. Learning and actions to be taken by the trust to prevent a recurrence will be shared with relatives as appropriate.

6. Risk assessments

Risks identified with the implementation of this policy (and procedure) have been assessed and mitigated as far as possible, in line with the Trust’s risk appetite. Should any further risks be identified following implementation, these will be assessed and consideration will be given to an urgent review/revision of the policy (and procedure).

7. Training needs

The Leadership team and Quality and Professional Development team will facilitate briefing sessions in each Business Unit to support staff embedding this policy into clinical practice. It will be ensured that staff reporting deaths have appropriate training and protected time under their contracted hours to review and investigate deaths to a high standard.

Training should include partnership working as deaths in the community usual involve several primary care and community partners. This is supported by:

values and behaviours that encourage engagement with families and carers
clear and consistent leadership
a positive, open, and learning culture
staff with resources, training, and support
positive working relationships with other organisations.

(National Quality Board 2018)

8. Monitoring compliance and effectiveness

All audits are subject to LCH audit processes.

Mechanisms that are used to share lessons include FabuLeeds, the Quarterly and Patient Safety meetings, and include publishing to the corporate intranet.

Requirement for monitoring and audit	Process	Lead for process	Frequency	Lead for reviewing	Lead for action plan	Lead for monitoring action plan
All deaths will be subject to a review (Section 5.2.1)	Audit of random samples of Level 1 and Level 2 documentation, as per annual audit plan	Business unit (BU) quality lead	Annual	BU clinical leads	BU quality lead	BU clinical leads
Duty of Candour process is enacted in accordance with the PL245 being open policy and Duty of Candour policy	Incidents of this nature to be included within the quarterly SI report to board	Risk and assurance manager	Quarterly	Head of clinical governance	Risk and assurance manager	Head of clinical governance
Where the death of a patient with a Learning Disability (LD) has occurred, this will need to be indicated on Datix and reported to the LeDeR (Learning Disabilities Mortality Review Programme) by the service	Review of Datix reporting to ensure all identified reports have been reported to LEDER	Learning disabilities lead	Quarterly	BU quality lead	Learning disabilities lead	BU quality lead

9. Approval and ratification process

The policy has been approved by the appropriate body and ratified by the Senior Management team on behalf of the board.

10. Dissemination and implementation

The Clinical Audit and Effectiveness team will support the dissemination of this policy by ensuring it is uploaded to the LCH Intranet and shared via the trust’s weekly newsletter, Community Talk.

Implementation will require:

operational directors, heads of service and general managers to ensure staff have access to this policy and understand their responsibilities for implementing it into practice
the Quality and Professional Development and Workforce department to provide appropriate support and advice to staff on the implementation of this policy.

11. Review arrangements

This policy will be reviewed by the author in three years following ratification or sooner if there is a local or national requirement.

12. Associated documents

PL245 Being Open and Duty of Candour Policy
PL268 Incident management policy (including serious incidents)
Quality, assurance and improvement group, terms of reference

13. References

13.1 Useful websites

NHS Improvement – Learning from deaths in the NHS

14. Appendices