Mental Health Mortality Review Programme


In A Nutshell:

The Improvement Academy provides on-site and/or virtual training for organisations wishing to use Structured Judgement Review methods in mental health or community settings. Training is delivered in a ‘train the trainer’ format to ensure sustainability across the organisation.

What is Structured Judgment Review?

Structured Judgement Review (SJR) is an evidence based retrospective case record review methodology developed and validated by Professor Allen Hutchinson at the University of Sheffield. It allows trained reviewers to identify and describe the quality of care received by patients and to create a score of that quality.


Why is it needed in Mental Health settings?

People with mental health problems have greater health needs and a reduced life expectancy compared to the general population. The Mazar review of deaths of people with a Learning Disability or Mental Health between 2011 and 2015 found that many Trusts were not reviewing deaths in mental health unless subject to a serious untoward incident.

In response to several national reports and expert recommendations, NHS England commissioned the National Mortality Case Record Review (NMCRR) to standardise mortality case note reviews in NHS Acute Trusts across England and Scotland. In November 2018, the Royal College of Psychiatrists launched a Mortality Review Tool to increase learning, both locally and nationally, through the review of deaths. This tool is based on the Structured Judgement Review methodology.


Mental Health SJR Training

The training introduces SJR, including its background, methodology and discussion around using the data collected and implementing SJR at an organisational level

Objectives of the training

  • To provide reviewers with the knowledge and expertise required to perform explicit structured judgement reviews (SJR) within their organisations.
  • To enable Mental Health organisations to collect information on the safety and quality of care of patients, supporting improvement initiatives and governance needs.

Please see case study examples of learning and improvement in the PDF downloads section below.

who we are working with

Royal College of Physicians

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