Mortality reviews collaborative: a review of learning

Produced by:

The National Mortality Case Record Review (NMCRR) programme has been working with other nationally commissioned mortality review programmes and confidential enquiries to explore sharing intelligence, collaboration opportunities and the potential for future reporting across the programmes.

Common themes

Reviews of recommendations and learning points from all the active programmes reveal a small number of generic issues that continue to affect healthcare across all sectors:

  1. Improvements in recognition and management of sepsis are needed to prevent premature mortality in all client and patient groups.
  2. Early detection of, and then appropriate escalation of, patients who are deteriorating or exhibit 'red flags' at presentation will further prevent premature mortality.
  3. Patients across all healthcare organisations sometimes continue to be denied life-saving therapies on the grounds of being older, pregnant or having a learning disability.
  4. Better communication both within organisations, and between organisations and healthcare agencies, will help avoid premature deaths.
Professor Marian Knight of the Maternal, Newborn and Infant Clinical Outcome Review Programme discusses the mortality reviews collaborative at the NMCRR conference in October 2018.