1. Introduction

1.1

Learning from deaths of people under our care can help us improve the quality of the care we provide to patients and their families, and identify where we could do more.

1.2

Findings from the Francis Inquiry report show that ‘higher than expected’ mortality rates were at worse ignored or manipulated and at best the subject of poorly functioning non-systematic mortality review meetings in which failings in the quality of care were not confronted or corrected. Essentially, there are three levels of scrutiny that a provider can apply to the care provided to someone who dies; death certification; case record review; and investigation. They do not need to be initiated sequentially and an investigation may be initiated at any point. A review of deaths of patients already takes place within the Trust through the incident reporting system (Datix) and identification of STEIS reportable incidents involving mortality.

1.3

The five year forward view for mental health in February 2016 (NHSE) identified that people with severe and prolonged mental illness are at risk of dying on average 15 to 20 years earlier than other people.

1.4

Additionally, reports and case studies have consistently highlighted that in England people with learning disabilities die younger than people without learning disabilities. The NQB guidance specifies that all inpatient, outpatient and community patient deaths of people with learning disabilities should be reviewed to enable learning and thereby contribute to service improvements.

1.5

The Learning Disabilities Mortality Review (LeDeR), commissioned by HQIP 1.5(Healthcare Quality Improvement Partnership), has an established and well-tested methodology for reviewing the deaths of people with learning disabilities. Trusts should notify all deaths of people with learning disabilities to the LeDeR programme. All deaths of people with learning disabilities should be investigated using the LeDeR methodology by LeDeR (see Appendix B).

1.6

The National Quality Board (NQB) guidance requires that all inpatient, outpatient and community patient deaths of people with severe mental illness (SMI) should be subject to case record review. In relation to this requirement, there is currently no single agreed definition of which conditions/criteria would constitute SMI. The term is generally restricted to the psychoses, including schizophrenia, bipolar disorder, delusional disorder, unipolar depressive psychosis and schizoaffective disorder. It is acknowledged that there is substantive criticism of this definition; personality disorders can be just as severe and disabling, as can severe forms of eating disorders, obsessive compulsive disorder, anxiety disorders and substance misuse problems.

1.7

The national bodies are working to clarify expectations about mortality review in mental health and community services in general. In the meantime, it is a requirement that the above description of SMI is used. You can also review the care provided to patients with other significant mental health issues such as those mentioned above, where this can be done proportionately and effectively.

1.8

Additionally, a Care Quality Commission (CQC) review in December 2016, 'Learning, candour and accountability: a review of the way trusts review and investigate the deaths of patients in England found that some providers were not giving learning from deaths sufficient priority and so were missing valuable opportunities to identify and make improvements in quality of care.

1.9

Following on from this in March 2017, the NQB introduced new guidance for NHS providers on how they should learn from the deaths of people in their care. That report required trusts to undertake a number of actions to ensure a systematic approach to identifying those deaths requiring review and a systematic, standardised approach to the performance, reporting and learning from those reviews following the death of people receiving care. Since September 2017 all Trusts in England have been required to have a process in place for mortality reviews.

1.10

The Royal College of Psychiatrists has subsequently issued guidance and a tool to be used for mortality reviews within mental health services.

1.11

Kent and Medway NHS and Social Care Partnership Trust (KMPT) believes that concentrating attention on the factors that cause deaths will impact positively on all persons who use services, and is required to demonstrate how it responds to, and learns from, deaths of people who either die while in our care or whose subsequent death may be attributable to our care. The aims are:

• 1.11.1 To support staff to review and learn from deaths and then take effective action to embed improvements and
• 1.11.2 To enable families and carers to raise and have answered questions or concerns about the care of patients who have died.

1.12

This policy describes our approach to learning from deaths and should be followed in conjunction with the Serious Incident Policy and Duty of Candour policy.