Each specialty (where applicable) will conduct mortality and morbidity meetings on a regular basis. These should be multi-disciplinary in nature and seek to identify areas where learning can be identified. Minutes and action logs should be completed to capture outcomes of mortality review and resulting actions and learning. Each specialty mortality review group will be chaired by a consultant Mortality Lead. The group will report to the directorate governance meeting and highlight any issues that will improve care and reduce avoidable mortality. The Inpatient Death Process and Coroner’s Inquests Policy (see section 12) provides information and guidance to all staff on the process and systems to follow in the event of a death, including certification of death and referral to the Coroner’s Office. The policy outlines legal requirements, individual responsibilities of staff, and explains the support and guidance available throughout the process. As required, the Trust will present information quarterly at the public meeting of the Board of Directors. This data will include the total number of the Trust’s inpatient deaths (including Emergency Department deaths, maternal deaths, neonatal deaths and stillbirths) and those deaths that the Trust has subjected to mortality review. Of these deaths subjected to review, the Trust will provide estimates of how many deaths were judged more likely than not to have been due to problems in care. The required mortality data will also be published in the Trust Quality Accounts from June 2018, including evidence of learning and actions as a result of information and an assessment of the impact of actions that the Trust has taken. Monitoring and Review What will be monitored How/Method/ Frequency Lead Reporting to Deficiencies/ gaps Recommendations and actions Policy review First review in one year and then every three years Author Mortality & Morbidity Group, Quality Assurance Committee This policy will be reviewed in conjunction with national guidance and Trust objectives. The policy will be published on the Trust Intranet. Number of deaths, including Learning Disability (LD) deaths specifically. Monthly Integrated Quality and Performance Report (IQPR) Mortality Learning Mortality & Morbidity Group, Quality Assurance Committee Any shortfalls identified will have an action plan put in to address which will have timescales included for re-audit / monitoring.
Number of eligible deaths reviewed, including LD deaths specifically. Quarterly reports to the Board Mortality Learning Mortality & Morbidity Group, Quality Assurance Committee, Public Board Any shortfalls identified will have an action plan put in place to address which will have timescales included for re-audit / monitoring. 2 mortality review outcomes – avoidability score Quarterly reports to the Board Mortality Learning Mortality & Morbidity Group, Quality Assurance Committee, Public Board Any shortfalls identified will have an action plan put in to address which will have timescales included for re-audit / monitoring. Time taken to return mortality review forms Monthly reports to directorates and the Trust Mortality & Morbidity Group Mortality Learning Mortality & Morbidity Group Appropriate action as necessary by the MMG where specialties/ directorates are identified as not meeting the required timeframe for review (30 days from request). Performance against key mortality metrics – crude death rate, HSMR and SHMI Monthly IQPR Mortality Learning Mortality & Morbidity Group, Trust Board Alerts will be investigated accordingly in collaboration with the Clinical Coding Team and relevant specialties.