Learning from Deaths Policy

Kent and Medway NHS and Social Care Partnership Trust believes that concentrating attention on the factors that cause deaths will impact positively on all persons who use services, reducing complications, length of stay and readmission rates through improving pathways of care, reducing variability of care delivery, and early recognition and escalation of concerns.

Publication date:
31 January 2021
Date range:
January 2021- September 2022

5. Duties

5.1 The Board of Directors

  • 5.1.1 The Board of Directors has overall responsibility for monitoring and learning from deaths across the Trust.
  • 5.1.2 A non-executive director will be responsible for the oversight of the programme and to ensure that progress is made against the national recommendations.

5.2 The Medical Director

  • 5.2.1 The Medical Director is responsible for ensuring the Trust complies fully with all national requirements for the programme.
  • 5.2.1 The Medical Director is responsible, with the Mortality Review Manager, to ensure allocation of a clinician to complete a Section 2 review.

5.3 The Trust-Wide Patient Safety and Mortality Review Group

  • 5.3.1 This group, under the chairmanship of the Director of Nursing and Quality, will be responsible for the review and monitoring of Trust learning from avoidable deaths.
  • 5.3.2 This group has the required multi-disciplinary and multi-professional membership and will meet monthly to oversee the process.

5.4 The Serious Incident and Mortality Panel

  • 5.4.1 The Serious Incident and Mortality Panel will be responsible for ensuring all deaths are reviewed. Every incident is considered on a case-by-case basis. The Panel will determine when a Section 2 review is required and escalate via the Mortality Review Manager.

5.5 Consultants and clinicians

  • 5.5.1 Consultants and clinicians nominated as clinical leads for the learning from deaths programme are responsible for ensuring the programme is delivered and functioning in line with national recommendations.
  • 5.5.2 Senior medical staff (ST4 and above) and senior members of other professional groups will be trained and participate in the process of case note review to support a thorough review process.

5.6 Mortality Review Manager

  • 5.6.1 The Learning from Deaths Manager will be responsible for managing the process of learning from deaths within the organisation and will report into the Trust-wide Patient Safety and Mortality Review Group as well as produce reports required at a national level.
  • 5.6.2 That person will also be responsible for ensuring the section 1 review is completed, and will also be responsible for liaising with the Medical Director to allocate Section 2 reviews.

5.7 The role of Medical Examiners

  • 5.7.1 The introduction of the Medical Examiner role is expected to provide further clarity about which deaths should be reviewed by actively identifying and allocating appropriate cases as per Trust policy.
  • 5.7.2 A national network of medical examiners was recommended by the Shipman, Mid-Staffordshire and Morecambe Bay public inquiries and in March 2016 the Secretary of State announced a consultation for their introduction from April 2019.
  • 5.7.3 The proposed role of the Medical Examiner will be to:
    • Scrutinise every death not requiring a Coroner investigation, provide expert advice and to confirm the doctor’s Medical Certification of Cause of Death ensuring the cause of death is accurate;
    • Discuss the cause of death with the family and address any concerns they may raise;
    • Identify patterns of causes of death; where indicated refer the death of any patient for review by the most appropriate provider organisation(s).
    • The exact role of the medical examiner will be clarified by research commissioned by NHS Improvement and the Department of Health. It is planned that the medical examiner service will cover all deaths, wherever they occur, by March 2021.