reviewing and monitoring mortality policy - adults€¦ · mortality review meetings - a mortality...

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The Newcastle upon Tyne Hospitals NHS Foundation Trust

Reviewing and Monitoring Mortality Policy - Adults

Version: 2.1

Effective From: 11 June 2018

Expiry Date: 26 September 2020

Date Ratified: 01 April 2018

Ratified By: Mortality Surveillance Group

1 Introduction

Following events in Mid Staffordshire, a review of 14 hospitals with the highest mortality noted that the focus on aggregate mortality rates was distracting Trust boards “from the very practical steps that can be taken to reduce genuinely avoidable deaths in our hospitals”. This was reinforced by the recent 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. It found that learning from deaths was not being given sufficient priority in some organisations and consequently valuable opportunities for improvements were being missed.

For many people death under the care of the NHS is an inevitable outcome and they experience excellent care from the NHS in the months or years leading up to their death. It is vital however, that providers have systematic, routine, multidisciplinary mortality reviews to enable teams to identify those areas where improvements can be made and that the correctible shortcomings in care that can lead to preventable deaths are addressed.

This policy closely follows the National Quality Board’s National Guidance on Learning from Deaths: A Framework for NHS Trust and NHS Foundation Trusts on Identifying, Reporting, Investigating and Learning from Deaths in Care (National Quality Board, March 2017) and stipulates the Trust, as an organisation, should respond to deaths of patients who die under its care.

2 Scope

This policy applies to all clinicians in all specialities. Implementation of the policy should be supported by administrative staff and managers as applicable. This policy applies to patients of 18 years of age or older.

3 Aims

The policy aims are as follows:

to clearly describe the process by which all deaths are identified, reported and investigated.

to ensure consistency in the quality of mortality reviews and the judgements made at the end of each review in regards to the quality of care delivered.

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to ensure that staffs engage meaningfully and compassionately with bereaved families and carers in order to properly answer questions they have in relation to the care delivered to their loved ones.

to ensure lessons learned are shared and acted upon. to define the process for monitoring mortality indicators such as Summary

Hospital-level Mortality Indicator (SHMI) and Hospital Standardised Mortality Ratio (HSMR)

4 Duties (Roles and responsibilities)

Chief Executive has overall responsibility for monitoring mortality rates on behalf of the Board of Directors of the Trust. Medical Director assures the Board that the mortality review process is functioning correctly. To ensure that arrangements are in place so that all clinical staff as appropriate are aware of their responsibilities to contribute to the process. Director of Quality and Effectiveness has delegated responsibility to support the implementation and further development of the Trust’s mortality monitoring process. This includes the provision of support staff and infrastructure to assist the clinical teams conducting mortality reviews as well as ensuring national and regional mortality data is monitored and acted upon as necessary. Directorate Managers and Clinical Directors ensure that appropriate multi-disciplinary mortality meetings take place in all specialities and meetings are fully documented. Mortality Meeting Chair Ensures:

Appropriate attendance by all relevant disciplines and professional groups

Case note reviews are undertaken of deceased patients and discussed at meetings

Collation of review findings, learning points and actions for improvement for each mortality meeting

Support requests for case note reviews following alerts/outlier notifications (see section 9)

Escalation of areas of concern to Mortality Surveillance Group (Meeting Secretary – Intergrated Governance Manager - Quality).

Medical staff

All consultant medical staff are required to participate fully in the M&M process.

All medical staff are expected to participate fully in all M&M meetings that are relevant to their practice

Nurses, allied health professionals and other clinical staff All healthcare professionals should be involved in mortality reviews meetings, as part of their clinical practice. This involvement could range from simply being aware of the outcome of such reviews insofar as they affect their area of practice, to full involvement in the production of data and implementation of recommendations

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5 Definitions

Avoidable/ Preventable- These terms are used interchangeably in the NHS and for the purpose of this policy ‘preventable’ or ‘unpreventable’ will be used with reference to whether anything could have been done to change the outcome.

Crude Mortality Rate - This is simply the total number of deaths as a percentage of the total number of inpatient admissions. Although this is not risk adjusted, it is often a good idea to monitor trends in crude mortality rates as it can quickly highlight when things are going wrong.

Health and Social Care Information Centre - An information and technology resource for the health and care system. They are responsible for compiling and monitoring national healthcare data and provide SHMI (see below) on a quarterly basis.

HED - An independent company that provides healthcare comparison data and enables healthcare organisations to benchmark their performance against their peers nationally.

Hospital standardised mortality Ratio (HSMR) - This is a methodology developed by Dr Foster to calculate the risk of death for hospital patients on the basis of clinical and hospital characteristic data. It is a ratio of the observed number of in-hospital deaths at the end of a continuous inpatient spell to the expected number of in- hospital deaths (multiplied by 100) for 56 specific Clinical Classification System (CCS) groups; in a specified patient group.

Mortality Database - This is an internal database to record all independent case note reviews and discussions held at speciality M&M meetings.

Mortality Review Meetings - A mortality meeting is where a multi-disciplinary group review and discuss clinical cases, outcome data and related information.

Mortality Surveillance Group - The Mortality Surveillance Group is a multidisciplinary team chaired by the Medical Director who meets on a quarterly basis to review and discuss Trust mortality data.

North East Quality Observatory (NEQOS) - Provide healthcare quality measurement and a programme of projects and services to teams and organisations across the North East. Using in depth reviews and surveillance measures, they assist organisations when they have particular issues to address. They also provide local benchmarking and identify opportunities for quality improvements. As part of this work they produce various reports looking at mortality data at a local and regional level.

Serious Incident (SI) - An accident occurring on NHS premises that resulted in serious injury, and or permanent harm, unexpected or avoidable death (ref to SI policy for further details Serious Incidents (SIs) Reporting and Management Policy ).

Summary Hospital-level Mortality Indicator (SHMI) - The SHMI is a ratio of the observed number of deaths to the expected number of deaths for a provider and is the main mortality indicator reported nationally and is supported by the Department of Health. The observed number of deaths is the total number of patient admissions to the hospital which resulted in a death either in-hospital or within 30 days post discharge from the hospital. The expected number of deaths is calculated from a risk adjusted model with a patient case-mix of age, gender, admission method, year index, Charlson Comorbidity Index and diagnosis grouping.

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6 Reviewing and Learning From Deaths

All areas are expected, as part of their governance arrangements, to adopt the overarching principles of routine and systematic mortality review, which includes reviewing all deaths.

A flow chart clearly depicting the minimum requirements for the mortality review process can be found in Appendix 1. Further details are outlined below.

6.1 Level 1 Review – ALL DEATHS

All deaths should be subject to a ‘level 1’ review. The aim of a ‘level 1’ review is to ascertain the type of review this death should receive and whether or not a more in-depth second stage review is necessary.

A level 1 review should consist of asking the following three questions:

6.1.1 Q1: Should this death be referred to the coroner?

Full details of the requirements for reporting deaths to the coroner and guidance on the completion of the necessary paperwork can be found in the [Reporting Deaths to The Coroner Policy]. A summary is found in Figure 1.

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Figure 1: Summary of Deaths to be reported to the Coroner

Death occurred as a result of poisoning, the use of a controlled drug, medicinal product or toxic chemical

Death occurred as a result of trauma, violence or physical injury, whether inflicted intentionally or otherwise

Death which might be related to any treatment or procedure at any time in the past;

- Surgery, diagnostic or therapeutic procedures/investigations/medical treatments or anaesthetic

All deaths where a medical procedure or operation has been performed in the preceding year must be discussed with the Coroner to meet requirements for cremation

Death occurred as a result of self-harm

Death occurred as a result of an injury or disease received during or contributable to, the course of the deceased persons work

Death occurred as a result of a notifiable accident, poisoning or disease

Death occurred as a result of neglect or failure of care by another person

Death was otherwise unnatural: - Death occurred when there were unusual or disturbing features

Death occurred in custody or otherwise in state detention of whatever cause

- NB a Deprivation of Liberty Safeguard (DoLS) order is no longer considered to amount to a state detention or to be equivalent to being in custody. As such it no longer mandates discussion with the Coroner unless other aspects of care indicate the need. -Death occurring when safeguarding issues are evident should still undergo Trust based level 2 review.

No attending practitioner attended the deceased at any time in the 14days prior to death

The identity of the deceased is unknown

Death of a child upto the age of 18

Death has not been certified (or if cause of death is unknown)

Death associated with childbirth or termination of pregnancy

Deaths occurring within 24hrs of admission

6.1.2 Q2. Did the death result from any of the following:

Maternal death (also see [Maternal Death Checklist] for further requirements)?

Unexpected death?

Death as a result of a VTE?

Death resulting from a HCAI?

Death following an unexpected admission to ITU?

Death where circumstances are subject to a Serious Incident or Never Event?

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Death where a staff member or family member/carer has raised a concern or where a serious complaint has been received

All families are to be given the ‘Information for Bereaved’ booklet which informs them of their right to discuss their loved one’s care with the health care team. The booklet will also provide them with the opportunity to raise any concerns they may have around the quality of care provided to their loved one and also to help inform decisions about whether a review or investigation is needed and to contribute to this if they wish to be involved. It is important at this difficult time to provide interpreters or other communication support required by family or carers. Interpreter and Translation Policy .

The booklet will be given to families via the Bereavement Office in conjunction with the death certificate. The Bereavement Office will be the first point of contact for families if they have a concern or query and wish to speak with the healthcare team. The Bereavement Office will record the details of the call and liaise with the necessary department or clinician who cared for the deceased (see Appendix 2 for further clarification).

6.1.3 Q3. Did the patient have either:

A Learning Disability? From the 1st August 2017 when a patient with a clear diagnosis of a learning disability dies, the death must be reported to the national Learning Disability Mortality Review programme (LeDeR). This notification will be completed by the Trust’s Learning Disability Liaison Service (LDLS). (See Appendix 3 for further details). The LDLS should be contacted on ext.: 20347 to inform them of any relevant deaths occurring within the Trust. Upon notification the LDLS will aim to meet with members of the clinical team within seven days of the notification of death and provide guidance and expertise to the review process. In addition to the standard mortality review questions the LDLS will ask if:

• the patient’s death unexpected and/or premature? • the patients learning disability impact on their death or the

outcome?

The findings are presented to the Trust Learning Disability Mortality Review Panel which is convened quarterly. Information is gathered including good practice, learning points and the need to consider a wider multi-agency review. The outcomes are then shared with the Trust’s Safeguarding Committee, the Learning Disability Steering Group and the Mortality Surveillance Group.

Or a Severe Mental Health Problem?

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A severe mental health diagnosis is, for the purpose of this policy, defined as any patient with a Care Programme Approach (CPA) in place. A CPA is a planned programme of care for people with severe mental health problems and would normally be issued by specialist mental health services.

Please contact Integrated Governance Manager – Quality on ext.: 20038 if a patient dies with a CPA in place. Notifcation can then be shared with Northumberland, Tyne and Wear (NTW) Trust.

If the answer to any of the above questions is ‘Yes’ then a ‘Level 2’ review should be undertaken.

6.2 Level 2 Review

A ‘level 2’ review should be undertaken by a multidisciplinary team with relevant clinical expertise.

All ‘level 2’ reviews should be enterted into the Trust’s mortality review database http://mortalityreview.app/ (link also available under ‘M’ on the ‘A to Z’ on the Trust’s intranet home page). In the unfortunate event of the database not working a paper version can be sought from CGARD (contact Integrated Governance Manager - Quality on extension 20038).

If the patient received care from more than one speciality, then the reviewing team may decide to ask another M&M to also review the patient’s care. This referral can be made via the M&M database.

Each ‘Level 2’ review should cumulate with an assessment of the care delivered to the patient prior to death. The reviewing team should consider all that they know about the patient's admission and rate the overall quality of healthcare received by the patient from this Trust, using the Hogan evaluation score and the National NCEPOD evaluation score below.

HOGAN Evaluation Score

1 Definitely not preventable

2 Slight evidence for preventability

3 Possibly preventable, but not very likely, less than 50-50 but close call

4 Probably preventable more than 50-50 but close call

5 Strong evidence of preventability

6 Definitely preventable

http://mortalityreview.app/

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NCEPOD Evaluation Score

1 Good practice: A standard that you would accept from yourself, your trainees and your institution

2a Room for improvement, Aspects of clinical care that could have been better

2b Room for improvement, Aspects of organisational care that could have been better

2c Room for improvement, Aspects of both clinical and organisational care that could have been better

3 Less than satisfactory: several aspects of clinical and/or organisational care that were well below that you accept from yourself, your trainees and your institution.

Data inputted into the mortality database will monitored by CGARD and the Mortality Surveillance Group within a combined table.

7 Escalting Concerns Related to Poor Quality Care

A death that has been clinically assessed and evaluated as having a HOGAN Evaluation Score rated >5 and/or NCEPOD evaluation score 3 will be referred to the to the Serious Incident (SI) Panel for review and consideration of next steps. Duty of Candour and an open and honest approach ensuring involvement of families will ensue should any preventable deaths be identified.

CGARD will monitor the mortality database on a regular basis to capture high evaluation scores and ensure these are acted upon.

If a family member/carer or healthcare professional raise a serious concern about the quality of care provided then a rapid review meeting is to take place, led by CGARD, to explore the concerns raised. The findings from this rapid review meeting will be reported to the SI panel for discussion and consideration of next steps.

8 Cross-System Reviews and Invesitgations

In many circumstances organisations other than the Trust are involved in the care of a patient who dies whilst in the care of the Trust, with the most common ones being primary care, ambulance services, other acute Trusts and mental health services. In the past, case record review has largely been restricted to review of records held by the Trust however it is sometimes possible to identify problems in care at earlier stages of the patient’s journey. Where this is the case, in the last few years, it has been possible to ask for reviews to be carried out by other organisations, however this has largely been restricted to other acute Trusts and the National Quality Board’s regulations make it clear that the NHS needs to substantially strengthen arrangements. As these arrangements come into place, it is expected that Trust staff will increasingly engage with cross-system reviews and investigations as required.

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9 Mortality Outliers and Alerts

9.1 Routine Mortality Surveillance

Crude mortality, SHMI and HSMR (when available) rates will be routinely monitored by CGARD both at a Trust and a Directorate level. This information will be presented quarterly at the Mortality Surveillance Group and at Trust Board on a monthly basis via the Quality Report and annually in the Quality Account.

9.2 Pro-active review of mortality outliers

Mortality outliers identified from internal surveillance and review of national/HED data will generate a specialty level case-note review. Any SHMI diagnostic group which has a mortality rate with a percentage difference greater than 20% from the expected mortality rate for four consecutive quarters will also undergo a case-note review.

Reports following this type of review will be presented to the Mortality Surveillance Group.

9.3 Reactive review of externally generated mortality outlier alerts

An appropriate clinician will be identified to conduct a review and produce a report within the timeframe prescribed by the Care Quality Commission. The process is supported by CGARD and Information Services. Reports generated as a result of this process will be presented to the Mortality Survellance Group.

10 Mortality Surveillance Group

The Mortality Surveillance Group is chaired by the Medical Director. The group meet on a quarterly basis to monitor and discuss mortality data including, SHMI, HSMR and mortality case note reviews. The group also receives regular updates and reports on deaths within the following patient groups - patients with a learning disability, a severe mental health diagnosis and patients who are 17 years or younger.

11 Training

No specific training is required for the implementation of this policy. However for advice relating to mortality monitoring techniques or for advice around the mortality monitoring database please contact the Clinical Governance and Risk Department.

12 Equality and diversity

The Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds. This document has been appropriately assessed.

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13 Monitoring Compliance

Standard / process / issue

Monitoring and audit

Method By Committee Frequency

Surveillance of mortality data

Report (dashboard) detailing current mortality data – including SHMI & HSMR

Integrated Governance Manager for Quality

Mortality Surveillance Group

Quarterly

Compliance with mortality alert/outlier process

Report detailing outcome of reviews and any lessons to be shared



Quarterly

Surveillance of Crude mortality rates and reviews

Report detailing all deaths and reviews including avoidable deaths into the monthly quality report and annual quality account.


Trust board Monthly

14 Consultation and review

Consultation was undertaken with the Medical Director, Mortality Surveillance Group,Clinical Coding Manager and Bereavement Office in order to ascertain the suitability of content and the applicability of the policy across differing clinical Directorates.

15 Implementation (including raising awareness)

Consultant staff will be informed about the policy and their roles in its implementation via email. An information leaflet detailing the Trusts mortality monitoring process with reference to this policy will also be placed on the Clinical Governance and Risk Departments intranet page.

16 References

NHS England, National Guidance on Learning from Deaths, March 2017 https://www.england.nhs.uk/wp-content/uploads/2017/03/nqb-national-guidance-learning-from-deaths.pdf

https://www.england.nhs.uk/wp-content/uploads/2017/03/nqb-national-guidance-learning-from-deaths.pdf

https://www.england.nhs.uk/wp-content/uploads/2017/03/nqb-national-guidance-learning-from-deaths.pdf

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The Newcastle upon Tyne Hospitals Mortality Review Process

Appendix 1

Level 1: review to be undertaken by attending clinician. The following questions to be asked:

Question 1: Does this death meet the requirements for a referral to the Coroner?

Yes

Refer death to coroner (see corners policy…)

AND

Conduct a level 2 review

Level 2 review

No

Question 2: Did death result from any of the following?

• Maternal death • Unexpected death • Death as a result of a VTE • Death resulting from a HCAI • Death following an unexpected admission to ITU • Death where circumstances are subject to an SI

or Never Event • Death where a staff member or family

member/carer has raised a concern • Death where a serious complaint has been

received

Yes Conduct a level 2 review

Question 3: Did the patient have a care programme approach (CPA) in place (a planned program of care for people with severe mental health problems)? OR Did the patient have a recognised learning disability?

No

Yes

For patients with a CPA contact Pauline McKinney (Ext. 20038) who will share this NTW.

For patients with a learning disability please notify Alison Forsyth (ext. 20347)

AND conduct a Level 2 Review

Level 2 reviews should be completed by:

A multidisciplinary team

Recorded onto the Trust mortality

database

Any actions/recommendations

recorded onto the Trust mortality

database

Any learning points to be shared with Directorate

Clinical Governance & Risk

Department to present data to


Clinical Governance & Risk

Department to monitor high

HOGAN and NCEPOD (HOGAN

>5 and NCEPOD 3) scores to

ensure appropriate escalation and

learning via the Mortality

Surveillance Group .

No

Level 1 review completed The completion of a level 2 review is now optional.

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Appendix 2

Bereavement Office Process Meeting the new Learning from Deaths Guidance (NQB, March 2017)

Call received by Bereavement Office following the offer of support ‘Information for The Bereaved’ leaflets.

SUBJECT OF PHONE CALL:

Further information/queries/ seeking clarification

Send to:

Clinical Lead/Matron

Cc Directorate Manager

Log on spreadsheet

Making a complaint

Send to:

Patient Relations Team

Log on spreadsheet

Patient Relations

Team follows

usual complaints

procedure.

Raising serious concerns about the

quality of care

Send to:

Clinical Lead/Matron Directorate Manager

AND: Integrated

Governance Manager – Quality

(adult death) Or Consultant in

Forensic Paediatrics (Child Death)

Log on spreadsheet

Rapid review meeting to be held with MDT - fact finding /RCA

Report outcomes to the Serious Incident panel for further guidance on next

steps

Bereavement Team

Patient Relations

CGARD/Paediatrics

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Appendix 3

THE NEWCASTLE UPON TYNE HOSPITALS NHS FOUNDATION TRUST

LEARNING DISABILITY MORTALITY REVIEW PROCESS

NuTH PATIENT dies with clear diagnosis of a learning

disability in Trust. Death Notified to LeDeR

Standard Trust Mortality Review process initiated. Level 2

reviews required

Learning Disability Liaison Service to meet with clinical team within a month of the notification of death (contact via e-mail x2) and review patient notes

To be reviewed at Directorate Mortality and Morbidity review and uploaded on to mortality database.

To consider

If the patient’s death was unexpected, premature?

Did the patient’s healthcare fall below an acceptable standard and lead to harm? (NCEPOD scale)

Was the patient’s death avoidable if the problems in healthcare had not occurred? (Hogan Scale)

Did the patients learning disability impact on their death or the outcome.

Trust Learning Disability Mortality Review Panel meet to discuss those deaths completed.

LEDER Review initiated externally. Trust contacted via Nursing and Patient Services Director. Information shared via attendance at review panel.

Outcome

Learning Points Captured. Action planned and lead identified. Lead to feedback to panel.

Report to Trust Mortality Surveillance Group

Trust Learning Disability Mortality Review Panel Membership:

Director Quality & Effectiveness AMD/CD for Quality Deputy Director of Nursing or Patient Services Learning Disability Liaison Service Head of Quality Assurance & Clinical Effectiveness. Head of Safegaurding Newcastle and Gateshead CCG LEDER Lead End of Life Lead available to support Out of Areas CCG LEDER Leads to attend where relevant.

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“An unexpected death is defined as a death which was not anticipated as a significant possibility 24 hours

before the death or where there was a similarly unexpected collapse leading to or predicating the events

which led to death”

“A death can be considered premature if without a specific event that formed part of the “pathway” that led to death, it was probable that the person would have continued to live for at least one more year” Heslop etal (2013) Confidential Inquiry into the premature death of people with learning disabilities. Norah Fry Research Centre. Bristol.

At any point did the patient’s healthcare fall below an acceptable standard and lead to harm?

NCEPOD

1 Good practice

2 Room for improvement in clinical care

3 Room for improvement in organisation care

4 Room for improvement in clinical and organisation care

5 Less than satisfactory

Is there evidence that the patient’s death was avoidable if the problems in healthcare had not occurred?

Hogan Scale

1 Definitely not avoidable

2 Slight evidence for avoidability

3 Possibly avoidable less than 50-50

4 Probably avoidable greater than 50-50

5 Strong evidence for avoidability

6 Definitely avoidable

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Appendix 4

Newcastle upon Tyne Hospitals NHS Foundation Trust

Level 2 Mortality Review

Criteria for reviewing patients

Deaths which should be reported to the Coroner and a level 2 review undertaken:

Death occurred as a result of poisoning, the use of a controlled drug, medicinal product or toxic chemical

Death occurred as a result of trauma, violence or physical injury, whether inflicted intentionally or otherwise

Death which might be related to any treatment or procedure at any time in the past; - Surgery, diagnostic or therapeutic procedures/investigations/medical treatments or anaesthetic

All deaths where a medical procedure or operation has been performed in the preceding year must be discussed with the Coroner to meet requirements for cremation

Death occurred as a result of self-harm

Death occurred as a result of an injury or disease received during or contributable to, the course of the deceased persons work

Death occurred as a result of a notifiable accident, poisoning or disease

Death occurred as a result of neglect or failure of care by another person

Death was otherwise unnatural: - Death occurred when there were unusual or disturbing features

Death occurred in custody or otherwise in state detention of whatever cause - NB a Deprivation of Liberty Safeguard (DoLS) order is no longer considered to amount to a state detention or to be equivalent to being in custody. As such it no longer mandates discussion with the Coroner unless other aspects of care indicate the need. -Death occurring when safeguarding issues are evident should still undergo Trust based level 2 review.

No attending practitioner attended the deceased at any time in the 14days prior to death

The identity of the deceased is unknown

Death of a child upto the age of 18

Death has not been certified (or if cause of death is unknown)

Death associated with childbirth or termination of pregnancy

Deaths occurring within 24hrs of admission

Other areas for a level 2 mortality review:

All maternal deaths

Any unexpected death

Death of a patients with a Care Programme Approach (CPA) in place ( a planned program of care for people with severe mental health problems)

Any death as a result of VTE

All deaths resulting from an HCAI

Death following an unexpected admission to ITU

Any death where the circumstances are subject to an SI or never event

Any death where a staff member, patient or family member/carer has raised a concern

Any death where a serious complaint has been received

Any death of a patient with a recognised learning disability

The Newcastle upon Tyne Hospitals NHS Foundation Trust

Equality Analysis Form A

This form must be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval.

PART 1 1. Assessment Date: 2. Name of policy / strategy / service:

Reviewing and Monitoring Mortality Policy

3. Name and designation of Author:

Pauline McKinney

4. Names & designations of those involved in the impact analysis screening process:

Pauline McKinney, Integrated Governance Manager

5. Is this a: Policy x Strategy Service

Is this: New Revised x

Who is affected Employees x Service Users x Wider Community

6. What are the main aims, objectives of the policy, strategy, or service and the intended outcomes? (These can be cut and pasted from your policy)

The purpose of this policy is to clearly describe the process in which all deaths within the Trust are identified, reported and

investigated. The policy will ensure consistency in the quality of patient mortality reviews within NuTH and provide clinicians with

clear guidance on which patients are to receive an in-depth review and to share the learning.

7. Does this policy, strategy, or service have any equality implications? Yes x No

If No, state reasons and the information used to make this decision, please refer to paragraph 2.3 of the Equality Analysis Guidance before providing reasons:

07/09/2017

8. Summary of evidence related to protected characteristics Protected Characteristic Evidence, i.e. What evidence do

you have that the Trust is meeting the needs of people in various protected Groups

Does evidence/engagement highlight areas of direct or indirect discrimination? If yes describe steps to be taken to address (by whom, completion date and review date)

Does the evidence highlight any areas to advance opportunities or foster good relations. If yes what steps will be taken? (by whom, completion date and review date)

Race / Ethnic origin (including gypsies and travellers)

Provision of Interprets Information available in other formats on request Mandatory EDHR Training

There are some differences in death rates for people with protected characteristics. These are taken into account in level 2 reviews. Use of professional interpreters is a factor in reducing clinically significant errors in communication (Flores et al 2003). Lack of interpreting was found to produce adverse effects for patients, practitioners, providers, public health teams, commissioners and communities (Stallabrass, 2011).

Incorporate communication support into section 9 of the policy. When data base is updated add a question to level 2 review: Was communication support required? Was communication support required? (Pauline Mc Kinney 2017)

Sex (male/ female) Mandatory EDHR Training

There are some differences in death rates for people with protected characteristics. These are taken into account in level 2 reviews.

No

Religion and Belief Chaplaincy Team available for advice and support. Bereavement Service Religious requirements in relation to death are taken into account within the bereavement process. Religion, Belief and Cultural Practices Policy and Guidance Mandatory EDHR Training

As above No

Sexual orientation including lesbian, gay and bisexual people

Death occurring as a result of a notifiable

As above No

accident, poisoning or disease are subject to level 2 review

Mandatory EDHR Training

Age All children who die aged 18 years or younger will be subject to a review. Specific services for Children and Young People and Older people Trust work in relation to Dementia Care Your’e Welcome Accreditation for Children and Young People’s Services Mandatory EDHR Training

As above No

Disability – learning difficulties, physical disability, sensory impairment and mental health. Consider the needs of carers in this section

All patients who die with a mental health diagnosis will be subject to a level 2 case note review. Death of people with a learning disability will be notified to the national Learning Disability Mortality Review programme and the Trust standard level 2 mortality review process then initiated. Provision of BSL Signers and Deaf Blind Guides LD Liaison Nurse, flagging of learning disability and patient passport. Trust work to support Carers Mandatory EDHR Training

Deaf adults in the UK have high rates of known risk factors for chronic disease, such as CVD, hypertension and diabetes, and high rates of self-reported depression. Lack of awareness, under diagnosis and Under treatment of chronic conditions may be putting them at risk of preventable ill-health and potentially reduced life expectancy. See http://bmjopen.bmj.com/content/5/1/e006668

Incorporate communication support into section 9 of the policy. When data base is updated add a question to level 2 review: Was communication support required? Was communication support required? (Pauline Mc Kinney 2017

Gender Re-assignment Mandatory EDHR Training There are some differences in death rates for people No

http://bmjopen.bmj.com/content/5/1/e006668

with protected characteristics. These are taken into account in level 2 reviews.

Marriage and Civil Partnership

Mandatory EDHR Training

As above No

Maternity / Pregnancy Maternal deaths and deaths associated with childbirth or termination of pregnancy are subject to a level 2 review. Mandatory EDHR Training

As above No

9. Are there any gaps in the evidence outlined above? If ‘yes’ how will these be rectified?

No

10. Engagement has taken place with people who have protected characteristics and will continue through the Equality Delivery

System and the Equality Diversity and Human Rights Group. Please note you may require further engagement in respect of any significant changes to policies, new developments and or changes to service delivery. In such circumstances please contact the Equality and Diversity Lead or the Involvement and Equalities Officer.

Do you require further engagement? Yes No x

11. Could the policy, strategy or service have a negative impact on human rights? (E.g. the right to respect for private and family

life, the right to a fair hearing and the right to education?

No

PART 2 Name:

Pauline McKinney

Date of completion:

07/09/2017

(If any reader of this procedural document identifies a potential discriminatory impact that has not been identified, please refer to the Policy Author identified above, together with any suggestions for action required to avoid/reduce the impact.)

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