Learning from deaths

As part of Surrey and Sussex Healthcare NHS Trust’s approach to the monitoring of patient outcomes and its commitment to quality improvement we routinely monitor mortality together with ensuring compliance with national requirements set out in national guidance on Learning from Deaths.

For many people death under the care of the NHS is an inevitable outcome whether this is from a fatal heart attack or coming to the end of their natural life. In any case it is important that the patient experiences excellent care from the NHS in the hours, months or years leading up to their death. In many cases this will be a dignified death, surrounded by their loved ones.

In 2016, the Secretary of State for Health commissioned a report following the high profile case at Southern Health NHS Foundation Trust in response to the very low number of investigations and reviews of deaths.  The Care Quality Commission (CQC)  published “Learning, Candour and Accountability: A review of the way NHS Trusts review and investigate the deaths of patients in England” which concluded that opportunities to improve care for future patients were being missed.

In line with this guidance, the Trust has in place the Learning from deaths policy which details how it responds to and learns from deaths of patients in our care. This also includes our process to comply with the Learning Disabilities Mortality Review (LeDeR) Programme.

The Trust also looks at various mortality indicators to help us better understand the risks of hospital treatments for individual patients, together with trends or changes in patterns over time which may direct us to where improvements may need to be made.

We do this using some key measures:

• Crude mortality rate – produced locally by the Trust
• Hospital standardised mortality rate (HSMR) – published nationally by Dr Foster Intelligence
• Summary hospital-level mortality indicator (SHMI) – published nationally by NHS Digital
• Mortality rates for consultant surgeons – published by the individual Royal Colleges
• National Audit – Published by HQIP