This 2019 publication from the RCP mortality team demonstrates evidence from across the NHS in England of improvements in patient care and safety from the process of structured judgement review.
This publication describes examples from healthcare organisations and systems on how they have structured their approach to learning from mortality case record review, and explicitly developed improvement programmes. Also included is focused learning from the national database on people who may have died from sepsis.
The themes identified in these case studies include work on:
- reducing pneumonia mortality rates
- the impact of the medical examiner system
- the impact of SJR in the emergency department
- reducing mortality in stroke patients
- using SJR to improve hip fracture care.
The findings from this research highlights the potential of both a national and local approach to learning and improving in this context.