National Mortality Case Record Review Programme

The National Mortality Case Record Review Programme (NMCRR) 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. As well as improve understanding and learning about problems and processes in healthcare that are associated with mortality.

What we are doing

We are currently implementing the RCP National Mortality Review tool (online platform) in trusts and health boards throughout England and Scotland. The platform is supported by Datix and is free of charge to all trusts and health boards wishing to implement.

The online platform offers a standardised mortality review process based upon the structured judgement review (SJR) methodology. This methodology is based upon the principle that trained clinicians use explicit statements to comment on the quality of healthcare in a way that allows a judgement to be made that is reproducible.

We are actively recruiting trusts and health boards wishing to implement the tool. Please email: mortality@rcplondon.ac.uk to express your interest.

Training

Following the publication of Learning from Deaths by the National Quality Board in March 2017 our approach to training in England changed. In an effort to ensure that capacity and capability exist to train hospital mortality reviewers more quickly, we have facilitated training sessions aimed at training tier one trainers. These trainers will sit locally as a resource for trusts to access to train hospital mortality reviewers.

A list of tier one trainers, their locations and contact details is available in the programme resources below. We encourage enquiries from trusts and academic health science networks (AHSNs) interested in scheduling additional SJR training sessions.

Please email Clare Wade, programme manager for the National Mortality Case Record Review: clare.wade@rcplondon.ac.uk.

About the NMCRR

The 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 (HQIP). The RCP collaborates with two partners to deliver the NMCRR Programme: the Improvement Academy (IA) in Bradford and Datix.

In January 2017 we completed the pilot phase of the programme. A full report and a summary are available to download.

The programme is mentioned within the National Quality Board – National Guidance on Learning from Deaths and our newsletter can be found on the NMCRR resources webpage along with a number of additional supporting materials.

How we store and use data

The RCP National Mortality Review tool (online platform) provides trusts and health boards with a platform to enter and analyse their own data for adult acute deaths in England and Scotland. This data will also be analysed by the NMCRR team on a national level to further inform learning.

The platform provides:

  • a secure, free of charge, supported platform for trusts and health boards to collate adult acute mortality reviews
  • anonymous mortality reviews (protecting patient privacy within this national system)
  • a bespoke analysis tool enabling trusts and health boards to conduct local analysis of their aggregated mortality review cases.

The platform is not designed to generate data for comparison of trust performance or to contribute to a national measure of the number of deaths contributed to due to problems in care. The data input locally can be analysed by each trust and health board to support their own learning and quality improvement initiatives. For more information about the security specifics, please contact: mortality@rcplondon.ac.uk.

For the purposes of the General Data Protection Regulation (GDPR), the data controller is Healthcare Quality Improvement Partnership (HQIP). HQIP, as data controller, may choose to share this data for the purpose of quality improvement, including research, service evaluation, and audit, if certain conditions are met. HQIP enacts its Data Controller responsibilities through its Data Access Request Group (DARG).

HQIP terms and conditions.

DARG is supported by HQIP’s Information Governance Advisory Group.

What we have produced

The NMCRR aims to improve understanding and learning about problems and processes in healthcare associated with mortality, and also to share best practice.
The National Mortality Case Record Review's annual report describes the programme's aims and objectives, along with its development and implementation.

The National Mortality Case Record Review (NMCRR) toolkit has been developed to support trusts in implementing a standardised way of reviewing the case records of adults who have died in acute hospitals across England and Scotland.

The NMCRR programme has been working with other nationally commissioned mortality review programmes and confidential enquiries to explore sharing intelligence and collaboration opportunities.
Watch our seminar 'Keeping patients safe – learning from mortality reviews to improve patient safety.'
The National Mortality Case Record Review Programme offers SJR training for colleagues in Scotland.
The WEAHSN set out to encourage and support a collaborative approach to the mortality review process across NHS trusts in the west of England.