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West of England Academic Health Science Network (WEAHSN) mortality case study

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The West of England Academic Health Science Network (WEAHSN) set out to encourage and support a collaborative approach across trusts in the region, with the aim of standardising the mortality review process, sharing learning and issues, triangulating outcome themes and facilitating region-wide quality improvement (QI) initiatives.


In mid-2016 colleagues at the west of England AHSN and their associated trusts became aware of an initiative the Royal College of Physicians (RCP) was undertaking in regards to introducing retrospective mortality case record reviews across England.

Colleagues across the west of England were keen to tie in the regional collaborative work already underway in the deteriorating patient domain to the RCP National Mortality Case Record Review programme (RCP NMCRR).

Consensus across all trusts was gained to set up a regional mortality review collaborative to introduce the RCP NMCRR through the use of the Structured Judgement Review (SJR) process.

The collaborative initially consisted of the following acute trusts within the region:

  • University Hospitals Bristol NHS Foundation Trust (UHB)
  • North Bristol NHS Trust (NBT)
  • Royal United Hospitals Bath Foundation Trust (RUH)
  • Great Western Hospitals NHS Foundation Trust (GWH)
  • Gloucestershire Hospitals NHS Foundation Trust (GH)
  • Weston Area NHS Trust (Weston).

Additionally Taunton and Somerset NHS Foundation Trust and Salisbury NHS Foundation Trust, who both fall under different AHSN catchment areas, contacted the WEAHSN to join the collaborative.

A local mental health trust, 2gether NHS Foundation Trust, has recently joined the collaborative to provide insight and experience on reviewing the deaths of patients known to mental health providers.


The WEAHSN joined the NMCRR programme as a pilot site where SJR training and operational implementation would be tested and fed back to inform the national programme.

In October 2016, SJR training was delivered by the NMCRR programme team to 44 clinicians from across the collaborative. Subsequently the WEAHSN has facilitated the cascade training of nearly 100 trainers across the region who will further support cascade training and the rollout of the SJR process at their respective trusts.

Supported by the WEAHSN, the collaborative hold a monthly steering group meeting which supports an open and honest culture and gives each trust a platform to update on their progress of SJR. Candid discussions take place which allow the group to collectively work through shared issues.

Included at these meetings are two patient and public involvement (PPI) representatives who help trusts to think how best to involve bereaved families and carers in their mortality review process. Two GP representatives also support the collaborative and will be the primary conduit for closing the feedback loop into primary care.

The collaborative approached the regional rollout with an early implementer methodology that saw three trusts testing the SJR methodology and process implementation and feeding back to the group. This allowed other trusts to accelerate their implementation plans when the national Learning from Deaths guidance was published and now all trusts are in the implementation phase.

The aim is for all trusts within the WEAHSN collaborative to implement SJR by March 2018; this date was revised back following the publication of the national Learning from Deaths guidance. Once all collaborative trusts have implemented the process, this will provide a rich pool of learning themes to further influence QI work within the WEAHSN region.

Most trusts have now developed operational process maps for their SJR process, detailing:

  • how and when mortality reviews should take place
  • case exclusions and inclusions
  • mechanisms for feedback to staff, teams and the board.

Identifying family care concerns and feeding back of review outcomes to families remains an area in development across the collaborative.

Each trust has additionally developed a trust policy which outlines how they aim to implement the national Learning from Deaths guidance, alongside the SJR process within their trust.

The individual screening tools developed and used by each trust are undergoing validation and a random selection of deaths screened out are retrospectively reviewed using the SJR methodology.

Reviewers at several trusts have now collectively screened 1,630 deaths between April and July with 499 undergoing an SJR review. Currently only one case has been assessed as having more than a 50% certainty of being avoidable. This case had already been identified under the trust serious incident framework. Approximately 14 reviews have identified slight evidence of avoidablilty and a number of learning points, including 28 for one trust.

Challenges and lessons learned

A number of issues and challenges have been identified through the collaborative which are being solved through the collective discussions.

Workload and feeding back to colleagues is a big concern for all the trusts, and currently most trusts are asking their clinicians to record the time it takes to undertake a review for job planning next year. Additionally it has been agreed that a clinician will be given no more than two reviews per month. Some trusts have shared the workload for high-volume specialties by training clinicians in other specialties such as anaesthetists and radiologists.

One trust has utilised a £45,000 charitable donation to fund a screening nurse, who will screen all deaths against their SJR screening tool to identify cases to be taken forward to a full review and release clinician capacity.

Timely access to notes and their overall quality has been problematic and is leading some trusts to review their patient record systems and processes and to feed back where reviews have identified poor quality of notes.

Feeding back the outcome of reviews both internally and externally has been a topic throughout the collaborative discussions. As an example, if a case scores 1 or 2 – indicating poor or very poor care in one of the trusts – the medical director (MD) team carry out a second, independent review. They then communicate with the team who provided the care to explore context; this approach puts the onus on the MD team and not the doctor undertaking the review to make the final decision on outcome.

Additionally, collaborative trust members feed back both poor and good/excellent care through a number of forums such as morbidity and mortality (M&M) meetings, dissemination though divisional leads and shared specialty dashboards.

However, feedback to external partners around care quality has proved more challenging, with difficulties noted in feeding back to primary care and community service providers. The shared regional approach has begun to change to enable these conversations at an individual level, but the collaborative have discussed ways of enabling these conversations at clinical commissioning group (CCG) and sustainability and transformation plan (STP) level, providing a feedback mechanism to out-of-hospital care providers.

It has become apparent that high-quality trust and divisional clinical leadership is integral to the effective implementation of SJR. Such leadership will not only be the driving force for implementing and spreading the use of SJR but will also be intrinsic in developing an open and learning-focused culture which encourages improvement actions to be developed from the themes identified.

Medical directors and non-executive directors are occasionally invited to the collaborative steering group, supporting the clinical leads in implementing the process within their own trust.

Finally, a number of challenges still remain, such as involving families and carers and 30-day discharge mortality, and this is where the collaborative is demonstrating its true worth. Collaborative trust members are working together to identify solutions to these challenges, capture and share best practices, and utilise member experiences and knowledge, such as PPI and GP representatives, to influence and inform such solutions.

Emerging themes and QI

The strongest theme to emerge from the WEAHSN collaborative has been that of senior review and earlier identification of patients who are end of life (EOL). Initiatives are under development across trusts covering how to recognise EOL, moving to symptom triggers and conversations with patients, families and carers.

It has been identified via the GP representatives from the monthly mortality meetings that patients are being sent to hospital inappropriately, with limited conversations happening with the patient, families or carers about their wishes.

Once patients enter the hospital, there is initially a focus on pathways for treatments (such as sepsis) as opposed to considering EOL care. The challenge is how to interface with community and GP services and how best to manage these patients so that everyone has appropriate expectations about escalation of care.


Significant progress has been made in the west of England on the introduction of the Structured Judgement Review process. Strength exists in a multi-level, multidisciplinary approach that a collaborative or buddy-type system can achieve and is recommended for any trusts looking to implement SJR.

Feedback gained from the collaborative noted how the structure provides a ‘safe space’ to discuss experiences, share best practice and collectively work through issues. Moving forward this group will also provide a platform for trust’s learning themes to be discussed, influencing quality improvement work being undertaken within the WEAHSN region.

Whilst the NMCRR programme is currently focused on acute trusts, the inclusion of members from other settings into the collaborative has enabled us to start developing the processes for shared learning across the system. This is recognised as integral for the delivery of higher quality and safer care as patients are rarely cared for by an individual organisation alone.

Who's involved


Collaborative main contributors:

  • Emma Redfern, trainer and associate clinical director for patient safety, WEAHSN
  • Mark Callaway, trainer and University Hospitals Bristol clinical lead
  • Kevin Hunter, WEAHSN patient safety programme manager
  • Deborah Evans, managing director, WEAHSN.

Other significant contributors to the collaborative:

  • Ann Remmers, WEAHSN patient safety programme director
  • Seema Srivastava, clinical lead, North Bristol
  • Mark Juniper, clinical lead, Great Western Hospitals
  • Chris Gallegos, clinical lead, Royal United Hospitals Bath
  • Pam Adams, clinical lead, Gloucestershire Hospitals
  • Claire Gorzanski, clinical lead, Salisbury Hospital.