About mortality reviews

Mortality review is a key development area throughout the NHS. Many trusts  already have a process for reviewing serious incidents and inpatient or mental  health deaths through existing national and local audits or through the Serious  Incident Framework. However, the focus on deaths has changed significantly  since the Learning from Deaths Guidance was issued in March 2017.

The main changes – driven by the now statutory requirement to identify both  numbers and learning – in the Health and Social Care Act Regulations on Quality  Account reporting are:

• knowing which of your patients have died and when;
• Identifying MH and LD patients;
• facilitating the identification of which of those deaths should be subject  to case review or further investigation; and
• demonstrating learning and improvement is implemented.

Alongside the widely publicised changes to Learning from Deaths comes an  increase in public expectation that families are involved and that any subsequent  learning is implemented.

The importance of learning from deaths:

Having effective systems and processes for learning from deaths does carry at least some resource requirement. However, most clinicians, managers and quality teams expressing the unequivocal view that the learning arising from deaths is worth it. Many indicate it is a ‘no brainer’; others say that the investment in the review process has impacted on staff and families positively – for example, the funding and introduction of Family Liaison Officers (FLOs) and along with it a culture that has improved communication and transparency with families.

Structured Judgement Reviews

The introduction of case note reviews – notably the Structured Judgement Review (SJR) process – supports the learning and development of care processes. Our practitioners were the first to use the Structured Judgement Review (SJR) Methodology across a health system.

Seeing first-hand the developing story of a patient’s care in the months before they die is an opportunity for learning in so many ways – record keeping; communication; timeliness; compassion; team working; good practice and of course, the identification of poor practice.

Our Mortality Governance Assurance Framework (MGAF)

About the Framework

Our Mortality Governance Assurance Framework (MGAF) has been
developed as the result of our work with a number of different organisations. The Framework can work if applied in a holistic way, i.e. if undertaking a whole-scale mortality governance review, or, aspects of the framework can be applied within services. The MGAF can also be applied across systems to enable broader learning and shared improvement to take place.

We understand how accountable healthcare organisations work

Our practitioners have worked extensively with, and within the NHS. We have a good mix of clinical, investigative and governance experience which underpins our unique methodology in this field.

We understand the challenges you face in applying limited resources to best effect, particularly in the vital sphere of learning from deaths. Our work has helped many organisations to improve care, to become safer and to demonstrate their commitment to continuous quality improvement.

Our way of working

Throughout our work in this specialist area, we have demonstrated our unerring commitment to meaningful engagement with all stakeholders and partners. Many of our recent assignments were high profile and delivered successful outcomes for our clients due to our pro-active and productive engagement approach.

Our way of working is collaborative and flexible. We will work in a supportive manner whilst providing appropriate levels of challenge and use our experience to provide external perspectives, insight and honest appraisal of the current state.

We develop good collaborative working relationships with our clients and their stakeholders at all levels. We have a reputation for honest advice whilst developing mutually supportive partnerships, enabling joint learning and relationship building. Our co-production approach means working alongside clients to capitalise on respective skills, facilitate knowledge transfer and secure buy-in. We have demonstrated this way of working repeatedly on all of our large scale, system-wide projects involving data collection and analysis, investigations and case reviews.

Our work often involves running engaging and inclusive workshops/focus groups for cross-sector audiences on specific topics and programmes of work. Team members have held recent numerous, regional collaborative workshops on mortality governance and a wide number of local/bespoke workshops with NHS and local authority partnership forums and other professional groups.

Mary-Ann Bruce – Associate Partner, Governance & Assurance
Mary-Ann led the first system-wide Clinical Quality Audit using Structured Judgement Review methodology.