Background

Harrogate and District NHS Foundation Trust cares for the population in Harrogate and the local area as well as across North Yorkshire and Leeds .It also provides children's services in County Durham, Darlington and Middlesbrough. The trust runs Harrogate District Hospital and Ripon Community Hospital.

The trust is part of the Improvement Academy regional Mortality Review Programme and uses the Structured Judgement Review (SJR) methodology for mortality reviews. Harrogate District Hospital is also a pilot site for the National Mortality Case Record Review programme.

The process

In-depth case notes reviews, using the SJR methodology, are carried out for

The trust also does in-depth reviews of mortalities where a complaint has been raised either by families/carers or through the incident reporting system, DATIX. In addition, it also takes into account its outlying mortality rates and CQC alerts in the case selection process. Second stage reviews are carried out by the trust's mortality lead.

Example of themes and quality improvement initiatives

Review of a cohort of deaths due to cerebrovascular accidents revealed timely imaging and timely transfers to the Hyperacute Stroke Unit, early involvement of families in decision making and prompt recognition of the dying patient. There was also appropriate consideration of brainstem testing and organ donation.

The reviews also identified areas for improvement including

Some actions taken by the trust following the cohort review were

The Future

Increase the number of trained reviewers in the trust while continuing to provide quality assurance to training and reviews.

Develop an improved system for case selection while adhering to the guidance provided by the national mortality framework announced in March 2017.

 

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 May 2017