On 28 November 2018, the Royal College of Psychiatrists (RCP) released guidance specifically focussing on learning from patient deaths for NHS mental health trusts. This is supported by NHS England and has been piloted in a number of mental health trusts.

The RCP have issued a ‘Care Review Tool’, a template for trusts to complete for patients who have died under their care, as well as accompanying guidance on how to use this. These documents were requested by NHS England and they aim to ensure that ways of improving services are learned from patients’ deaths. This includes identifying good practice which can be shared as well as sub-standard care.

The documents focus on individuals who are likely to have severe mental illnesses, such as bipolar disorder or anorexia and died, where there is no Sudden Untoward Incident review (or RCA) being carried out. It deals with the identification of ‘red flags’ that necessitate a further review of the individual’s care. Examples of red flags include, but are not limited to, whether family members or staff had raised concerns about the individual, or that the individual was a psychiatric inpatient at the time of death or had been discharged within the last month. In these cases, the trust should to complete a ‘structured judgement review’ within the tool, which prompts the trust to analyse various aspects of the individual’s care and then rate the quality of this care. The tool also includes sections to be filled in relating to whether the care was below standard, and if so, whether this resulted in harm to the patient.

The accompanying guidance provides examples of the type of feedback that should be entered within all sections to ensure that this feedback is comprehensive and therefore increase the chances that areas requiring improvement are identified.