20 February 2018

UCLPartners event shows links between learning from deaths and organisational culture

UCLPartners brought together representatives from 14 organisations across the region in January to discuss how to overcome challenges to best learn from deaths through mortality reviews.

Over 40 attendees heard from the Dr Andrew Gibson from the Royal College of Physicians on the Structured Judgement Review (SJR) methodology. Local trust, Whittington Health presented their approach to learning from deaths, which included linking reviews to quality improvement objectives, promoting family and carer involvement, as well as overcoming challenges to produce timely reports. And Basildon and Thurrock Hospitals and Mid-Essex Hospitals talked about their experience of overcoming high mortality rates, as well as developing and implementing the NHS Smart app to streamline and guide mortality reviews and learning across three trusts in Essex.

The talks were followed by multiple table and group discussions about different strategies, challenges and solutions to undertaking mortality reviews as well as best approaches to implementing and spreading learning from mortality reviews.

Key learning included:

  • Most hospitals in attendance were already undertaking mortality reviews using SJR
  • Some are currently setting up systems and processes to start reviewing deaths
  • Some hospital trusts train doctors, nurses and surgeons to review deaths, whilst others are considering employing and training medical examiners to review the care that preceded the death of a patient.

The group also discussed current and expected challenges related to undertaking mortality reviews. Key challenges included:

  • Screening and identification of appropriate death cases for review
  • The number of reviews to be allocated to a reviewer, and funding to pay reviewers
  • The set-up of training processes
  • The documentation of care in patient records
  • Effective sharing of learnings internally and beyond organisational boundaries
  • How London Ambulance Services should approach mortality reviews.

Much of the discussion focussed on culture; specifically, the shifting of blame away from systems to individuals, fear of being criticised and the use of mortality reviews in coroner courts, where individuals might be held accountable for having been involved in the provision of care for a patient, whose death could be considered “avoidable”, may impact on learning and the process of undertaking these.

Participants agreed that a culture that facilitates open and multi-professional learning will be essential to address themes that would most likely come out of the reviews.

Ideas to facilitate learning and inform improvements in care included:

  • Regular learning and sharing sessions
  • Safety huddles
  • News bulletins
  • Simulation training based on learnings from death as well as approaches such as learning from excellence.

We are now in the process of exploring how to support our partners to maximise learning from death. At the same time, we are liaising with NHS Improvement London and other AHSNs, who also support their stakeholders and partners to improve learning from death.