In line with the CQC's recommendations in its review of how the NHS investigates patient deaths at the end of last year, the National Quality Board has recently published the first edition of a new national framework for NHS Trusts - 'National Guidance on Learning from Deaths'.
The purpose of the new framework is to introduce a more standardised approach to the way NHS Trusts report, investigate and learn from patient deaths, which should lead to better quality investigations and more embedded learning.
It covers how Trusts respond to deaths in care generally, not just those amounting to 'serious incidents', which will continue to be dealt with under the existing 'Serious Incident Framework'.
The focus of the new framework is on improving governance processes around patient deaths (including new board leadership roles, a new system of 'case record reviews', quarterly reporting of specific information about deaths in care and a new Trust policy on how individual organisations will be implementing all this) and on ensuring the families/carers of patients who have died in care are properly involved at every stage.
Going forward, the CQC is likely to be keeping a close eye on how Trusts are doing in terms of compliance with the new framework.
What do Trusts need to do under the new framework?
The framework requirements apply to all acute, mental health and community NHS Trusts and Foundation Trusts.
As detailed below, the framework focuses on two key areas - improving governance around patient deaths and greater involvement of families/carers.
The drive to improve Trust governance processes around patient deaths as part of the new framework has numerous specific elements to it, including:
The new framework places a lot of emphasis on the importance of Trust Board leadership in ensuring that learning from patient deaths becomes truly embedded in their organisations. It makes clear that mortality governance needs to be a priority for Trust Boards.
Reflecting this, Trusts are required to identify an existing executive director to be 'Patient Safety Director', with responsibility for the learning from deaths agenda. They also need to identify a non-executive director to take responsibility for oversight of progress. On this point, considerable emphasis is placed in the guidance on the role of non-executive directors as a 'critical friend' in holding the organisation to account for its approach to learning from deaths, particularly those assessed as having been avoidable (see 'Case Record Reviews' below).
Case Record Reviews
Whilst Trusts will already undertake some form of mortality reviews, a central plank of the new framework is the requirement for all Trusts to introduce a system of 'case record reviews'. This will involve an objective review of the patient's records for all deaths falling within selected categories. Trusts can determine for themselves exactly how the case record review system will work in their organisation, but the guidance sets out minimum requirements for the types of case which should be subject to a case record review, including all deaths where families/carers or staff have raised a significant concern about the death, all deaths of those with learning disabilities or severe mental illness and all deaths in areas where people are not expected to die (e.g. elective procedures).
The guidance suggests that Mental Health Trusts and Community Trusts will want to consider carefully which categories of outpatient and/or community patient will come within the scope for case record review, taking a proportionate approach.
This process will affect a much broader range of cases than serious incident investigations, which will continue to be carried out in line with the existing Serious Incident Framework.
The purpose of the case record reviews will be to determine whether there were any problems in the care provided to the patient who died and, if there were, whether the death is likely to have happened as result of those problems - i.e. whether it was a potentially avoidable death.
The reviews should be carried out using an evidence-based methodology. A particular methodology suggested in the guidance as an example is the 'Structured Judgement Review', which the Royal College of Physicians will be rolling out training on. The guidance refers to how this can be adapted in the mental health context and explains that there is a separate methodology which must be used for learning disability cases.
The guidance further specifies that case record reviews should wherever possible be conducted by clinicians who were not directly involved in the deceased's care.
Setting up this system may not be straightforward and it is acknowledged in the foreword to the guidance that: "There will be legitimate debates about deciding which deaths to review, how the reviews are conducted, the time and team resource required to do it properly, the degree of avoidability and how executive teams and boards should use the findings".
New 'dashboard' data
Under the new framework, Trusts are now also required to comply with new data reporting requirements relating to patient deaths.
This will mean publishing the following information each quarter - total number of deaths in the Trust's specified scope (as a minimum, all adult inpatient deaths excluding maternity), total number of deaths subject to a case record review and total number of deaths assessed to have a more than 50% chance of being avoidable.
A template 'dashboard' has been provided to assist with collating and publishing this information.
In terms of timeframes, the guidance is asking Trusts to publish details of their policy and approach via public board meetings by the end of Q2 and to start publishing the data (plus learning points) from Q3 onwards.
A summary of this data - plus information about how the organisation has learned from deaths - will also have to be published as part of Trust Quality Accounts from 2018.
Policy for responding to deaths
Trusts will also be required - by September 2017 - to publish a policy setting out how the organisation responds to and learns from patient deaths.
The framework outlines the areas this policy should cover, such as the Trust's approach to undertaking case record reviews (as described above), including their system for selecting which deaths to review and the rationale for this.
The policy should also set out how the Trust's processes respond to the deaths of people in the following specific groups - those with a learning disability or mental health needs, infant/child deaths and stillbirths or maternal deaths.
Under the new framework, Trusts should review whether their staff have appropriate skills and specialist training to support this agenda, including ensuring that staff have protected time under their contracted hours to review and investigate deaths to a high standard.
National training is to be rolled out on the 'Structured Judgement Review' method for undertaking the new system of case record reviews.
The other key message from the new framework is that Trusts must make it a priority to work more closely with the families/carers of patients who have died to ensure meaningful support and engagement at all stages, from notification of the death right through to actions taken following an investigation.
The framework sets out key principles for Trusts to follow, including the need to treat bereaved families/carers as equal partners and recognising that paying close attention to what families/carers say can offer an invaluable source of insight to improve clinical practice.
The Trust's policy on responding to patient deaths should include details of how the Trust supports and engages with the family/carers of patients who have died, including ensuring they have a proper opportunity to raise questions or share concerns about the quality of the patient's care.
Under the minimum requirements in the framework, a significant concern raised by families/carers should always trigger a case record review.
It is worth emphasising that this guidance is described as a 'first edition' and it is envisaged that it will evolve and be revised over time as organisations learn what works best. The National Quality Board has indicated, for example, that some revisions to the guidance may be made following on from a recent national Learning from Deaths Conference.
The guidance also refers to further upcoming developments to look out for, including:
- Under its revised inspection regime, the CQC will strengthen its assessment of how providers learn from deaths - e.g. via proposed new 'well-led' assessment questions specifically related to this
- National guidance for bereaved families is in the pipeline
- New statutory guidance for child death reviews is to be published later this year