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The West of England AHSN ‘Collaborative Approach to Learning from Deaths’ has been shortlisted for an HSJ Patient Safety Award, in the Clinical Governance & Risk Management category.

The Collaborative Approach to Learning from Deaths began in September 2016. Our Patient Safety team partnered with the Royal College of Physicians to be an early adopter of their Structured Judgement Review (SJR) process.

The SJR is a standardised approach to reviewing case records of people who have died in care. Reviewing records can help providers improve the quality of care provided to patients and their families. It can also help identify where more can be done in future.

Using our experience in delivering collaborative work we approached all acute hospitals in the region to improve learning from deaths. Our aim was to standardise the mortality review process, share learning and issues and facilitate local and region-wide quality improvement (QI) initiatives.

The screening process was found to be effective in ensuring full reviews were focused on relevant cases. A total of 506 deaths were reviewed between April and August 2017. Most were rated either good or very good, one deemed avoidable and 17 slight evidence of avoidability.

One major theme the collaborative recognised was a failure to quickly recognise end of life palliative care across settings. As a result of the reviews, one trust is now sending a ‘poor prognosis’ letter to GPs of discharged patients who they feel are nearing the end of their life.


Next steps

The final round of judging begins on 30 April, where the team will present the entry to a panel of judges.  The winners will then be announced at the HSJ Patient Safety Awards in Manchester on 9 July.

Congratulations to all involved in the project, and to all others shortlisted.


Posted on April 9, 2018

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