Background

Doncaster and Bassetlaw Hospitals NHS Foundation Trust serves a population of more than 420,000 across south Yorkshire, north Nottinghamshire and the surrounding areas and runs three hospitals:

The trust uses the Improvement Academy's Structured Judgement Review (SJR) methodology for systematic mortality reviews.

The process

 

Example of themes and quality improvement initiatives

The most common theme was that of missed opportunities in recognising end of life therefore resulting in unnecessary interventions in a dying patient. This led to an awareness raising campaign across the Trust via a variety of routes such as lunchtime lectures, specialty presentations and individual leadership. The trust is already seeing an improvement in timely recognition and management of the dying patient.
Admissions from care homes and other community care settings that are deemed to be unnecessary are analysed and information fed back via the Clinical Commissioning Groups.
Improved coding of learning disability patients through better liaison with the Learning Disability Specialist Nurse

The Future

More timely reviews. This is crucial should any issues with care be highlighted and the need for duty of candour to be applied.

Discussions are being held to identify a process for ensuring any care issues highlighted by family members prior to death trigger the involvement of the family in a case review.

Agree the format for a report to be made to the Board on avoidable deaths.

 

If you would like an update on the progress of the above trust with regards to mortality reviews and quality improvement initiatives, please contact usha.appalsawmy@yhahsn.nhs.uk

Last updated April 2017