Mortality report shows hospitals are learning from deaths to improve patient care

Hospitals are using a standardised review approach to learn from adult acute deaths and improve patient care, a landmark report released by the RCP reveals today.

The publication of Learning from deaths by the National Quality Board in March 2017 mandated all English trusts to conduct mortality reviews, a move supported by the RCP's National Mortality Case Record Review (NMCRR) Programme. Funded by NHS Improvement and commissioned by the Healthcare Quality Improvement Partnership, the NMCRR has developed the structured judgement review (SJR) process to effectively review care received by patients who have died.

The NMCRR's 2018 annual report cites a number of case studies where the SJR has made positive contributions to improving healthcare for patients. For example, Buckinghamshire Healthcare NHS Trust introduced medical examiners and the SJR process to screen all deaths in 2017. Within just 6 months 97% of deaths were screened and 12% of all cases used the SJR process. This has resulted in:

  • informing improvements in end-of-life (EOL) care including promoting patient choice
  • encouraging formulation of personalised care plans in the hospital and the community
  • improved sepsis recognition and treatment
  • increased awareness of timely DNACPR (do not attempt CPR) decisions and treatment escalation plans (TEP).

Since 2016 the National Mortality Case Record Review (NMCRR) has been implemented in over 100 NHS trusts and health boards across England and Scotland. The NMCRR team has trained around 480 healthcare professionals across England and Scotland, who in turn have shared their training with at least 1,500 other healthcare professionals including doctors and nurses.

Our advice is that mortality reviews and other quality improvement initiatives should be fully embedded across all NHS trusts.

Professor David Oliver, RCP clinical vice president

Dr Andrew Gibson, consultant neurologist and clinical lead for the NMCRR, said:

This pioneering NMCRR programme aims to implement a validated, standardised way of reviewing the case records of adults who died in hospitals across England and Scotland.

The report demonstrates that through using a standardised review approach NHS trusts can successfully improve quality in patient care and safety. It also highlights the significant efforts required to implement the programme nationally and the enthusiasm from those involved to work collaboratively.

Professor David Oliver, RCP clinical vice president and consultant in geriatrics and general internal medicine at Royal Berkshire NHS Foundation Trust, said:

Nearly half of deaths in the UK happen in hospital and quite rightly there has been growing political and professional focus in recent years on improving end-of-life care, support for the bereaved, and learning from and ultimately eliminating preventable deaths. It is therefore really positive to see that the use of our SJR validated, structured tool is already contributing to positive changes.

So far we have trained 450 reviewers to use the SJR approach who are supporting hospitals to identify good practice and areas for improvement and develop stronger cultures of openness, learning and partnerships with families. There is still much to do, and our advice is that mortality reviews and other quality improvement initiatives should be fully embedded across all NHS trusts.

About structured judgement review (SJR)

SJR was developed to replace variable local systems with a standardised, national, evidence-based method. The SJR tool enables understanding of the care delivered to adult patients before death in acute hospitals in a way that data from clinical coding and death certification cannot. SJR maximises the potential for learning and improvement, and encourages the development of quality improvement initiatives when problems in care are identified. Importantly, the SJR also helps identify good practice for sharing within the NHS.

The SJR process can also be used for a wide range of hospital-based safety and quality reviews, across services and specialties – not only for cases where people die in hospital. For example, it has been used to assess the care of people who have had a cardiac arrest in hospital, to review safety and quality of care before and during admission to intensive care, and to review the care for people who are admitted at different times of the week.

For more information or to arrange an interview please contact Joanna Morgan, RCP Care Quality Improvement Department communications manager, on +44 (0)20 3075 1354.

Notes to editors

Royal College of Physicians

The Royal College of Physicians (RCP) plays a leading role in the delivery of high‐quality patient care by setting standards of medical practice and promoting clinical excellence. The RCP provides physicians in over 30 medical specialties with education, training and support throughout their careers. As an independent charity representing over 35,000 fellows and members worldwide, the RCP advises and works with government, patients, allied healthcare professionals and the public to improve health and healthcare.

NMCRR Programme

The National Mortality Case Record Review (NMCRR) Programme contract was awarded to the RCP in February 2016 and is funded by NHS Improvement and commissioned by the Healthcare Quality Improvement partnership. The RCP collaborates with two partners to deliver the NMCRR Programme: the Yorkshire and Humber Improvement Academy in Bradford and Datix UK. The programme aims to develop and implement a standardised methodology for reviewing the case records of adults who have died in acute hospitals across England and Scotland. The programme also aims to improve understanding and learning about problems and processes in healthcare that are associated with mortality, and to share best practice.

Buckinghamshire Healthcare NHS Trust

Buckinghamshire Healthcare NHS Trust provides a wide range of high-quality acute and community services from two acute hospital sites in Stoke Mandeville and Wycombe, five community hospitals at Amersham, Buckingham, Chalfonts and Gerrards Cross, Marlow and Thame, and a number of community sites across the county, as well as in patients’ own homes. 

Around 6,000 staff serve residents across Buckinghamshire, Thame (Oxfordshire), Tring (Hertfordshire) and Leighton Buzzard (Bedfordshire) – a combined population of 500,000. It serves a much larger population (1.5 million) for burns and plastic services and 14 million for spinal injuries.