cwp - learning from deaths policy · 2018. 6. 7. · 5. learning disabilities mortality review...

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Document level: Trustwide

Code: GR47 Issue number: 2

Learning from Deaths Policy Lead executive Director of Nursing, Therapies & Patient Partnership

Authors details Complaints and Incidents Manager - 01244 393 146 Head of Clinical Governance - 01244 393 387

Type of document Policy Target audience All CWP staff

Document purpose

To describe how CWP learns from deaths of patients who die when receiving care or had received care from the Trust in the last 6 months leading up to their death. The policy also outlines how the Trust engages with bereaved families and carers, including how they are supported by the Trust and involved in investigations where relevant.

Approving meeting Quality Committee Date 09/05/2018 Implementation date 09/05/2018

CWP documents to be read in conjunction with GR1 GR4

Incident reporting and management policy Policy for the recording investigation and management of complaints concerns

Document change history

What is different?

Quick reference flow chart refined 4.1 Introduction of the mortality comparison tool Improved death categories and definitions 4.3 Further clarification when a death is reportable as an incident on Datix Unexpected death category and definition table inserted 4.4 Further clarification when a case record review is required Expected death category and definition table inserted 5 Engaging with bereaved families, carers

Appendices / electronic forms

Appendix 1 – Case record review form amended Appendix 2 – Top 10 tips for family engagement Appendix 3 – Bereavement support and advice information

What is the impact of change?

Will improve the scope and number of deaths of people under our care that we can review to identify learning and improve experience of others as part of the future care that we provide.

Training requirements

Yes - Training requirements for this policy are in accordance with the CWP Training Needs Analysis (TNA) with Education CWP.

Document consultation Central & East locality Lead Manager Investigations – Central & East

Wirral locality Consultant in Patient Safety Specialist Health Facilitator

West locality Deputy Clinical Services Manager - Home Treatment Corporate services Director of Nursing Therapies & Patient Partnership

Associate Director of Safe Services Associate Director of Information & Performance

http://www.cwp.nhs.uk/resources/policies/gr1-incident-reporting-and-management-policy/

http://www.cwp.nhs.uk/resources/policies/gr4-policy-for-the-recording-investigation-and-management-of-complaints-concerns-compliments/

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Head of Clinical Governance Complaints and Incident Manager

External agencies N/A Financial resource implications No

External references 1. Learning, candour and accountability - CQC, December 2016 2. National Guidance on Learning from Deaths - National Quality Board, March 2017 3. Implementing the Learning from Deaths framework: key requirements for trust boards - NHS

Improvement, July 2017 4. Independent review of deaths of people with a Learning Disability or Mental Health problem in

contact with Southern Health NHS Foundation Trust April 2011 to March 2015 – Mazars, December 2015

5. Learning Disabilities Mortality Review Programme – Bristol University, April 2017 6. Learning from deaths - one year on – NHS Improvement, December 2017

Equality Impact Assessment (EIA) - Initial assessment Yes/No Comments Does this document affect one group less or more favourably than another on the basis of: - Race No - Ethnic origins (including gypsies and travellers) No - Nationality No - Gender No - Culture No - Religion or belief No - Sexual orientation including lesbian, gay and bisexual people No - Age No - Disability - learning disabilities, physical disability, sensory

impairment and mental health problems No Is there any evidence that some groups are affected differently? No If you have identified potential discrimination, are there any exceptions valid, legal and/or justifiable? Select Is the impact of the document likely to be negative? No - If so can the impact be avoided? N/A - What alternatives are there to achieving the document without

the impact? N/A

- Can we reduce the impact by taking different action? N/A Where an adverse or negative impact on equality group(s) has been identified during the initial screening process a full EIA assessment should be conducted. If you have identified a potential discriminatory impact of this procedural document, please refer it to the human resource department together with any suggestions as to the action required to avoid / reduce this impact. For advice in respect of answering the above questions, please contact the human resource department. Was a full impact assessment required? No What is the level of impact? Low

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Contents Quick Reference Flow Chart ................................................................................................................. 4 1. Introduction ................................................................................................................................. 5 2. Policy Synopsis ........................................................................................................................... 5 3. Background ................................................................................................................................. 5 4. How we respond to and learn from deaths .................................................................................. 6 4.1 Notification of a patient death ...................................................................................................... 6 4.2. Reporting a death on clinical system ........................................................................................... 6 4.3. Reporting unexpected deaths on Datix ....................................................................................... 6 4.4.1 Did the review identify a problem with care? ............................................................................... 8 4.5 Weekly Meeting of Harm reviews ................................................................................................ 8 4.6 Did the person have a learning disability? ................................................................................... 9 5. Engaging with bereaved families/ carers ..................................................................................... 9 5.1 Offer condolences ..................................................................................................................... 10 5.2. Let families/ carers know they can ask questions ...................................................................... 10 6. Learning from the review of the death ...................................................................................... 10 6.2 Wider learning........................................................................................................................... 10 7. Training .................................................................................................................................... 10 8. Reporting requirements ............................................................................................................ 10 9. Evaluation ................................................................................................................................ 11 Appendix 1 – Case Record Review for Expected Deaths ................................................................... 12 Appendix 2 – Top 10 Tips for family engagement ............................................................................... 15 Appendix 3 – Bereavement support and advice services .................................................................... 16

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Do not retain a paper version of this document, always view from the website www.cwp.nhs.uk to ensure it is the correct version

Quick Reference Flow Chart

Day

1

Notification of a patient

death

Contact family/ carer to offer

condolences in a timely manner

Family and carer engagem

ent should be an ongoing principle

Report Death on clinical

system

Let families/ carers know they

can ask questions

Is the death unexpected?

(see definitions)

Yes Allocate a

family liaison officer

No

Day

1-7

Completing a case record

review

No

Further Action

No

4.4.1 Did the review identify

a problem with care?

Ensure Duty of Candour

(See GR1 – Incident policy)

Yes

Report the death on Datix to consider level of

investigation (follow GR1 - Incident reporting

and management policy - Quick Reference Flow Chart)

No

Did the person have a learning disability?

Yes

Weekly Meeting of Harm will review: All inpatient

deaths 5% of deaths

reviewed as no problems with care

A decision will be made if a thematic review is

appropriate.

The Incident Team will notify the LeDeR

programme

http://www.cwp.nhs.uk/



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1. Introduction In March 2017, the National Quality Board published the first edition of the National Guidance on Learning from Deaths to help standardise and improve the way that NHS trusts identify report, review, investigate and learn from deaths, and how they engage with bereaved families and carers. This was reinforced by the findings of the Care Quality Commission (CQC) report Learning, candour and accountability: A review of the way NHS trusts review and investigate the deaths of patients in England published in December 2016. It found that learning from deaths was not being given sufficient priority in some organisations and consequently valuable opportunities for improvements were being missed. The report also pointed out that there is more that the NHS can do to engage families and carers and to recognise their insights as a vital source of learning. Its purpose is to help initiate a standardised approach, which will evolve as the health care system learns. NHS Improvement has published further guidance, ‘Implementing the Learning from Deaths framework: key requirements for Trust boards’. NHS Improvement is encouraging trusts to learn from each other and challenge each other to continuously improve the quality of their Learning from Deaths processes and the implementation of effective and sustainable improvements as a result. NHS England is also leading work to further determine what support bereaved relatives and carers can expect from trusts, this is due to be published in 2018. Cheshire and Wirral Partnership NHS Foundation Trust has consulted and worked with trusts across the Cheshire and Merseyside footprint to ensure a whole systems approach to overseeing implementation and sharing processes as we evolve. 2. Policy Synopsis The policy describes how CWP intends to respond to and learn from deaths of people who die when receiving care or had received care from the Trust in the last 6 months leading up to their death. The policy also outlines how the Trust engages with bereaved families and carers, including how they are supported by the Trust and involved in investigations where relevant. The purpose of the policy is to review and investigate deaths to identify if there was a problem in care, in order to learn and prevent recurrence, whilst further improving our engagement with bereaved familes and carers. 3. Background A Quality Improvement approach will continue to help measure the impact of the requirements to review all deaths as outlined in the ‘National Guidance on Learning from Deaths’. It will also measure the quality of learning and capacity to do so at a local and corporate level. The Director of Nursing, Therapies and Patient Partnership is the Board appointed patient safety director who will be responsible for the ongoing learning from deaths agenda and policy. The Non-Executive Director and Chair of the Quality Committee has responsibility for the oversight of the learning from deaths agenda. They have a duty from an independent perspective to constructively challenge the Board on decisions in ensuring clinical quality controls and systems of risk management are robust and defensible.

A mortality task and finish group (involving executive membership and representation from multi-disciplinary teams) will continue to make improvements to strengthen methods in identifying and reviewing deaths associated with problems in care to focus efforts on identifying and integrating learning. The policy will be reviewed as recommended by the group.


http://www.cqc.org.uk/sites/default/files/20161213-learning-candour-accountability-full-report.pdf



https://improvement.nhs.uk/uploads/documents/170720_Implementing_LfD_-_information_for_boards_proofed_v2.pdf

https://improvement.nhs.uk/uploads/documents/170720_Implementing_LfD_-_information_for_boards_proofed_v2.pdf

https://www.england.nhs.uk/publication/national-guidance-on-learning-from-deaths/

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4. How we respond to and learn from deaths 4.1 Notification of a patient death How we will determine which deaths to review As a minimum we will review all deaths of people accessing CWP care, (including people discharged

from our care within 6 months of their death), i.e. where a person was accessing the following episodes of care:

Inpatient care Community mental health treatment under CPA Community treatment for identified mental health, learning disability, physical health or substance

misuse needs Supervised community treatment (subject to a community treatment order) If the person meets the above criteria and dies in another healthcare provider or custodial establishment, a discussion must take place with the provider to agree if a joint or single review is to take place and who is going to engage with the family. A record of the discussion must be documented within the clinical record. A Mortality Comparison Report uses information made available via NHS Digital and is the definitive list of people who have died. The report is matched to patient information (from CAREnotes, PCMIS and EMIS) and any people who have died are flagged on the report. Multi-disciplinary teams should regularly access the report (accessible to staff with access to report manager) to ensure all the deaths requiring review are acted upon. 4.2. Reporting a death on clinical system Refer to local guidance to record the death on the clinical system, e.g. CAREnotes, EMIS, and PCMIS. 4.3. Reporting unexpected deaths on Datix All unexpected deaths should be reported onto Datix. Where serious incidents have been disclosed, the usual risk management processes should be followed, please refer to GR1 - Incident reporting and management policy in conjunction with the NHS England Serious Incident Framework: Supporting Learning to prevent recurrence. An expected death would only be reported onto Datix if the case record review identified there may have been a problem in the care provided see section 4.4. A Family Liaison Officer needs to be allocated as soon as possible. Ideally, this should be on the day of the Trust knowing that the death is or may be a serious incident or there may have been a problem in care. The death categories and definitions to be reported on Datix are described in table below.

Datix category Datix sub category Definition Examples

(this list is not exhaustive)

Death

Unexpected Death- natural causes suspected

Natural causes suspected - Coroners would be expected to be an interested party

Sudden cardiac arrest – no previous heart condition, stroke, road traffic accident

Unexpected Death - serious incident suspected

Serious incident suspected Incidents team will report to NHSE

Suspected suicide, domestic homicide, abuse, neglect

Expected Death – problem in care provided

Person died within by an expected cause and the case record review identified there may have been a problem in the care provided.

Terminal illness, palliative care, Drug/ alcohol related, heart disease, liver disease


http://reportmanager.cwp.nhs.uk/Reports/Pages/Report.aspx?ItemPath=%2fCorporate%2fMP_001+Mortality+Comparison+Report

http://nww.cwp.nhs.uk/Documents/PoliciesandProcedure/GR1%20Incident%20reporting%20and%20management%20policy%20Issue%2010.pdf


http://www.england.nhs.uk/wp-content/uploads/2015/04/serious-incidnt-framwrk-upd.pdf

http://www.england.nhs.uk/wp-content/uploads/2015/04/serious-incidnt-framwrk-upd.pdf

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4.4. Completing a case record review Multi-disciplinary teams should complete a case record review form when an expected death is identified of people accessing CWP care, (including people discharged from our care within 6 months of their death). The death categories and definitions were a case record review is required are described in table below.

Category Definition Examples (this list is not exhaustive)

Expected Death -Complete a case record review -Coroners would not be involved

Person died within an expected timeframe and by an expected cause

Terminal illness, palliative care

Person died, not from the cause or timescale expected

Drug/ alcohol related, heart disease, liver disease

The case record review form is available on CAREnotes and EMIS. A paper form should be used until it is available on PCMIS. This form will help multi-disciplinary teams to: Apply our 6Cs principles in reflecting on the care provided by the whole team and, just as

importantly, in reflecting on the experience of care from the patient’s perspective. Make recommendations on further action, e.g. share learning, undertaking reviews. 4.4.1 Did the review identify a problem with care? Yes – Problem with care identified A nominated member of the MDT will record their rationale, where they feel care could have been a contributory or causal factor of the death, within the clinical care record, e.g. CAREnotes, EMIS, PCMIS, and report their findings to the clinical team. A nominated member of the MDT must report the death as an incident using the Trust’s electronic incident reporting form in Datix on the DIF1 form (or paper copy if not available - as part of business continuity, for example). No – Problem with care not identified A nominated member of the MDT will record their rationale within the clinical care record, e.g. CAREnotes, EMIS, PCMIS, stating no further action required. 4.5 Weekly Meeting of Harm reviews The group is responsible for receiving case record reviews where a problem in care delivery or service provision has been identified. The incidents team will place the review on the agenda for the proceeding weekly meeting of harm. The weekly meeting of harm group will review, challenge and clarify learning points for organisational implementation, identifying themes for improvement and ensure acceptable performance of the process. The weekly meeting of harm group will review all inpatient deaths. A quarterly clinical audit of 5% of deaths assessed as adequate care provided will be reviewed using quality improvement methodologies will be overseen by the Clinical Champion for Learning from Deaths. The incidents team will monitor the number of deaths reported on a monthly basis and alert the weekly meeting of harm of any potential increases which could be seen as an early warning sign. The weekly meeting of harm will decide if a thematic review is appropriate. The weekly meeting of harm group will act as the gatekeeper for raising concerns about patient care with other agencies involved. They will agree the next level of investigation using the 72 hour patient safety review to help identify if the death was potentially avoidable, for example: Local Internal Investigation – An internal review of the care provided.


http://nww.cwp.nhs.uk/TeamCentre/SafeServices/complaints/PublishedDocuments/Case%20Record%20Review%20-%20Pilot%20template%20April%202018.doc

http://datix.cwp.nhs.uk/datix/datixlive/

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Clinical Peer Review – An expert group of CWP professionals will review care provided. Level 1 – A full investigation reviewing the last episode of care to understand the root causes and

learning. Level 2 – A full investigation into the whole care provided by the Trust to understand the root

causes and learning. Level 3 – A full investigation into the whole care provided by the Trust to understand the root

causes and learning. Usually led by an Executive Member and chaired by a non executive director.

Thematic Review – A qualitative data analysis method that benefits from a collective review of problems in care, usually similar events occurring in proximity to one another (spatially or temporally), to identify any links.

4.6 Did the person have a learning disability? Yes – Person did have a Learning Disability The incidents team will ensure the Datix report is notified to the Learning Disabilities Mortality Review (LeDeR) Programme. Statutory mandated investigations must take precedence to the LeDeR review. Once all mandated investigations are completed a LeDeR investigation can commence. The Trust may be asked to participate in the multiagency review of these deaths and contribute to any actions recommended as part of the review. No – Person did not have a Learning Disability No further action required if the case record review did not highlight any problems in care delivery or service provision. 5. Engaging with bereaved families/ carers Engaging respectfully, sensitively and compassionately with families and carers of dying or those who have died is crucially important. The principles of openness, honesty, and transparency as set out in the Duty of Candour (see appendix 2 within GR1 - Incident reporting and management policy) should also be applied in all communication with bereaved families and carers. The Trust’s principle is that communication with healthcare teams, staff, people who access Trust services, their relatives and carers must be as open as possible. A family liaison officer will be allocated when care appears have been a contributory or causal factor of the death. Top 10 tips for family, carer engagement (see Appendix 2) 1. Early contact & write a letter – say sorry, we will investigate, provide a dedicated point of

contact. 2. Identify all the family – make sure you know all appropriate family members. 3. Be sincere – provide a high standard of bereavement care which respects confidentiality, values,

culture and beliefs, including being offered appropriate support. 4. Know your stuff – you need to be knowledable to be able to support families and carers, inform

them of their right to raise concerns about the quality of care provided to their loved ones. 5. Be open & transparent – be clear, honest, compassionate and sensitive; respond in a

sympathetic environment. 6. Offer meaningful involvement – enable families and carers to contribute to investigations to the

extent, and at whichever stages, that they wish to be involved, as they offer a unique and equally valid source of information and evidence that can better inform investigations.

7. Signpost – includes providing, offering or directing people to specialist bereavement support see bereavement support and advice guidance appendix 3.

8. Be professional – be emotionally intelligent, if you are upset speak to your line manager or colleagues. Utilise staff support services.

9. Learn effectively – make meaningful recommendations following contacts. 10. What if it were you? – consider this.



http://nww.cwp.nhs.uk/teamCentre/peopleservices/Pages/PeopleServicesHomePage.aspx

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Bereaved families and carers who have experienced the review or investigation process, should be supported if they wish to work in partnership in delivering training for staff in supporting family and carer involvement. 5.1 Offer condolences Always offer condolences to the family and/or carer/s. You should: Ask if they have any questions about the care that was provided. Keep the communication open for when the family/ carer is ready. Ask if they would like to be involved in reviewing the care records. Document discussion and rationale for decisions made. Provide the family/ carer bereavement support (see top 10 tips above).

5.2. Let families/ carers know they can ask questions Ensure families and carers know they can ask questions or raise concerns and that they will be considered when determining whether or not to review or investigate a death. Involve families and carers from the start and throughout any stage of the review or investigation as far as they want to be. Offer to involve families and carers in learning and quality improvement as relevant. In order for this to be successful, teams need to: Ensure records have the correct contact details for the family/ carer. Staff supporting the family/ carer have the necessary skills and knowledge of the person who has

died, respecting privacy. Consider the most appropriate time and method to make contact – usually, this could be on the

day of the death notification, but no later than 5 days. (If police liaison/ Coroners offices are involved, contact may be via this route).

Consider the most appropriate environment (telephone/ home/ hospital).

6. Learning from the review of the death Learning from the review of the death will be triangulated with other quality data such as complaints, incidents, clinical audit findings, to inform the Trust’s continuous improvement programme and safety priorities. Themes emerging will be presented in the Learning from Experience report to the Quality Committee three times a year. Lessons learned will be shared with clinical services via local Learning from Experience groups. Safety bulletins and share learning bulletins will be distributed where appropriate. The learning from deaths will be reported monthly to Board and published on the CWP website. 6.1 Local learning Individual and team learning will be supported locally by the MDT, through clinical and management supervision; and local learning from experience groups. 6.2 Wider learning The Safe Services Department is collaborating with trusts within the Cheshire and Merseyside footprint, and wider, to encourage a whole systems approach to effectively implementing the emerging national guidance, and agree a plan to enhance inter-agency working. 7. Training MDTs will be educated and skilled-up in order to undertake case record reviews to enable them to make a balanced judgement as to whether care delivery/ service provision may have been contributory or causal factor of a person’s death. Protected time should be given to the MDT to undertake reviews. 8. Reporting requirements Information on deaths, reviews, investigations and resulting quality improvements will be collated, published and reported to Board via the Trust’s Learning from Experience report. An annual review of this information will be reported in the Trust’s Quality Accounts, including a detailed narrative account


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of the learning from reviews/ investigations, actions taken through the preceding year, with an assessment of the impact and actions planned for the year ahead. 9. Evaluation The Trust is committed to continually learning and improving in relation to the care and support it provides to the populations it serves. This also includes how the Trust manages and investigates incidents and deaths. Part of our Quality Improvement work will be to identify the best way to receive feedback in relation to families and carers when they are bereaved. This will also include evaluation of the family liaison role. There are several aspects that need to be included for evaluation, once the mortality task and finish group agree the approach. Audit cycle. Quality of the investigation. Timeliness of the investigation. Accuracy of identifying issues with care delivery. How we have responded and supported families during the process (this will be through 1 to 1

meetings, audit and focus groups).


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Appendix 1 – Case Record Review for Expected Deaths This form is part of EMIS and CAREnotes electronic care record and in under development to be part of the PCMIS electronic care record. The paper form should be used for teams not using electronic records. The form can be accessed by: For CAREnotes: For EMIS:


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GR47 – Case Record Review for Expected Deaths (for clinical systems)

Name of Patient Date of Birth/Age:

NHS Number: Ward/Team Name:

Date of Death: Place of Death:

Cause of Death:

Death reported to Coroner?

Inquest to be held?

Date last seen by service: Date of Discharge

(if applicable)

Diagnosis: CPA Level/MHA status

Medication:

What were the circumstances of the death?

Question Yes No No, but

not material to death

N/A N/K Please provide brief rationale for your answer

Have the family raised any concerns at the time of this review?

What was the date of the last risk assessment?

Have any risk events occurred since the last assessment of risk?

Was the date of the last care plan?

Did the plan of care identify the risks and address the care need?

Was the plan of care and risk management plan being followed?

Did an annual physical health review take place considering medication prescribed?

Were all potential safeguarding issues identified and acted upon reported to safeguarding team?

If the patient did not to attend appointments was appropriate action taken in line with policy?


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Question Yes No No, but

not material to death

N/A N/K Please provide brief rationale for your answer

Has the team raised any concerns about the care delivered by CWP or another organisation?

Other agencies/organisations involved?

Please state: N/A

What would the team have done differently?

Any other comments

In your clinical opinion what needs to happen next?

Please tick

Please briefly explain your rationale

No problems in care/service delivery identified No Further Investigation (This will be quality assured by audit)

Review identified that there may have been a problem in the care provided Patient Safety Review Required (Report death on Datix)

Review identified that there may have been a problem in the care provided by another organisation identified (Report death as an interface incident on Datix)

Name of MDT/Clinical Reviewer/s: Position: Date: Expected Death Definition Expected Death – service user died within an expected timeframe and by an expected cause (e.g. terminal illness, palliative care) Expected Death – service user died not from the cause or timescale expected (e.g. drug/alcohol related, heart disease, and liver disease) Version 2: To be used from 1st April 2018 – review 31 March 2019


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Appendix 2 – Top 10 Tips for family engagement


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Appendix 3 – Bereavement support and advice services BEAD Bereaved through Alcohol and Drugs Website: www.beadproject.org.uk Bereavement through a loved one’s drug or alcohol use is a devastating, challenging and often isolating experience. BEAD’s peer support volunteers have had an immense impact improving the emotional wellbeing of a number of individuals bereaved in this way, and this website allows us to broaden the reach of this support, providing a wealth of information and resources to those unsure where to turn or what to do in such a difficult situation. The website’s features include:

Outlining where and how to access appropriate support Helping people through the grieving process by looking at the emotions one might be

experience and how to overcome them Providing practical help with the things one will have to deal with a result of their loss Displaying stories and personal experiences Linking to useful resources and relevant organisations

www.bereavementsupport.co.uk Bereavement Advice Centre Helpline: 0800 634 9494. Bereavement Advice Centre supports bereaved people on a range of practical issues via a single free phone number. It offers advice on all aspects of bereavement from registering the death and finding a funeral director through to probate, tax and benefit queries. Carers UK Freephone: 0800 808 777 Child Bereavement Support and Information Line: 0800 02 888 40 Child Bereavement is a national charity which helps grieving families and the professionals who care for them and they have offices in Runcorn. Cruse Bereavement Free Phone: 0800 808 1677 Website www.curse.org.uk Email [email protected]. Cruse Bereavement supports people after the death of someone close. Face-to-face and group support delivered by training bereavement support volunteers across the UK. Young Peoples Service Freephone: 0800 808 1677 Website: www.RD4U.org.uk Email: [email protected] Department of Work and Pensions Website: www.dep.gov.uk Rosie Crane Trust Helpline: 01460 55120 Email: [email protected] The Rosie Crane Trust supports bereaved parents through their grief after the loss of a son or daughter of any age.


http://www.beadproject.org.uk/

http://www.bereavementsupport.co.uk/

http://www.curse.org.uk/

mailto:[email protected]

http://www.rd4u.org.uk/


http://www.dep.gov.uk/


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Samaritans Helpline: 08457 90 90 90 Freephone: 116 123 The Samaritans are a national organisation offering support to those in distress who are feeling suicidal or despairing and need someone to talk to. Survivors of Bereavement Suicide Helpline: 0300 111 5065 The Compassionate Friends: Supporting Bereaved Parents and their Families Helpline: 0345 123 2304 The Compassionate Friends are a charitable organisation of bereaved parents, siblings and grandparents who have suffered the death of a child or children.
