BHT Adult Mortality Review Process/BHT Reference No 215/Version 1.0 Issue No 1.0 Final Sept 2017 Buckinghamshire Healthcare NHS Trust Adult Mortality Review Process Once printed off, this is an uncontrolled document. Please check the intranet for the most up to date copy. Version: 1.0 Issue: 1.0 Approved by: DOC, EMC, Quality Committee and TPSG Date approved: 5 th September 2017 Ratified by: Quality Committee Date ratified: 5 th September 2017 Author: Julia Phillips Project Lead Mortality Review Clinical Nurse Lead for Sepsis, Critical Care Outreach Lead Director: Tina Kenny Executive Lead and Medical Director Name of Responsible Individual/ Committee: Quality Committee Consultation: BHT staff involved in care of the dying, the deceased and bereaved families/carers. All staff involved in mortality review and subsequent quality improvement as outlined in this policy. BHT Document Reference: BHT Policy Number 215 Department Document Reference (if applicable): Date Issued: Review Date: October 2019 Target Audience: All BHT staff involved in care of the dying, the deceased and bereaved families/carers. All staff involved in mortality review and quality improvement as outlined in this policy.
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BHT Adult Mortality Review Process/BHT Reference No 215/Version 1.0 Issue No 1.0 Final Sept 2017
Buckinghamshire Healthcare NHS Trust
Adult Mortality Review Process
Once printed off, this is an uncontrolled document. Please check the intranet for the
most up to date copy.
Version: 1.0
Issue: 1.0
Approved by: DOC, EMC, Quality Committee and TPSG
Date approved: 5th September 2017
Ratified by: Quality Committee
Date ratified: 5th September 2017
Author: Julia Phillips
Project Lead Mortality Review
Clinical Nurse Lead for Sepsis, Critical Care Outreach
Lead Director: Tina Kenny
Executive Lead and Medical Director
Name of Responsible Individual/
Committee: Quality Committee
Consultation:
BHT staff involved in care of the dying, the deceased
and bereaved families/carers. All staff involved in
mortality review and subsequent quality improvement as
outlined in this policy.
BHT Document Reference: BHT Policy Number 215
Department Document Reference
(if applicable):
Date Issued:
Review Date: October 2019
Target Audience:
All BHT staff involved in care of the dying, the deceased
and bereaved families/carers. All staff involved in
mortality review and quality improvement as outlined in
this policy.
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Location: Buckinghamshire Healthcare NHS Trust
Equality Impact Assessment: Completed
Document History
BHT Mortality Review Process
Version Issue Reason for change Authorising body Date
For natural deaths where there is no reason to consider discussing the death with the
Coroner, an email from the ME to the Registrar will NOT be sent.
If in doubt, the ME should send an email to the Registrar. Failure to do so may delay
registration.
When the Bereavement Services staff phone the NoK with the MCCD number they
will inform them that a call will be received from an ME in the near future. They will
also explain the role of an ME to explain why they will be ringing.
If, when collecting the MCCD, the NoK say they have not spoken to a ME yet,
bereavement office staff should ask the relatives if they have any questions about the
cause of death indicated on the MCCD. If they do, the Bereavement officer will offer
the opportunity for the family to speak to the ME on duty or another senior doctor.
6.4 Preparation for Screening and completion of Cremation Forms
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6.4.1 After the discussion with the ME, the case notes will be returned to the Bereavement Office, where the Bereavement Officer will make a record of the case on the Chapel Shared Drive.
6.4.2 The Bereavement officer will prepare the case notes for ME screening. This preparation includes:
Ensuring that the MCCD has been completed by the certifying doctor.
Ensuring GP notification has been completed by the doctor via DOCGEN
Obtaining the cremation form, if needed, with Part 1 completed by the certifying
doctor.
Updating the Chapel Shared Drive
Commencing a Medical Examiner Screening Form (see appendix 2)
Attaching relevant paperwork to the front of the case notes and passing the case
notes to the ME for screening.
6.5 Completion of Cremation Forms where applicable
6.5.1 Where the NoK have identified that the deceased is to be cremated AND where the certifying doctor has been instructed to complete the MCCD, the ME will complete the part 2 cremation form.
6.5.2 The ME who has already been involved in the discussion with the certifying doctor (who will do the part 1 form) should do this where possible, as another ME will need to speak to the part 1 doctor in order to be able to complete part 2.
6.5.3 The ME must complete all the legal process for completing the part 2 cremation form, including viewing the body of the deceased.
6.5.4 The ME who completes the part 2 cremation form must not have taken part in the care of the deceased in their last illness.
6.5.5 If it becomes clear that the ME cannot contact the certifying doctor, it is acceptable to speak to another doctor who cared for the deceased. If a replacement cremation form part 1 will have to be completed this will have to be explained in this case. It should be a rare occurrence.
6.5.6 Normally the ME will speak to the NoK, but where this does not happen before they complete the part 2 cremation form, the ME may speak to a doctor or nurse who cared for the deceased in their final illness. This will allow a cremation form to be completed.
6.6 Screening the case
6.6.1 An ME will screen each death within BHT – the roll out of the ME role will commence at
Stoke Mandeville Hospital (SMH) working towards screening all BHT deaths in the future
in accordance with the learning from deaths quality standard¹
6.6.2 Where possible the screening will be done by the same ME who had already discussed
the case with the certifying doctor.
6.6.3 The ME who completes the screening must not have taken a part in the care of the
deceased in their last illness.
6.6.4 Screening will normally involve the following steps, usually but not invariably in this order:
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A conversation with the certifying doctor, to agree the cause of death, to ascertain
whether the coroner needs to be informed of the death, and to ask whether, in the
opinion of the certifying doctor, there were any problems in the appropriate delivery of
healthcare to the deceased. In most cases this conversation will already have taken
place, but in order to satisfy the cremation regulations the conversation may have to
be repeated if a new ME is completing the process on the following day.
Proportionate examination of the medical records. The ME has discretion over how
long to take on this. In apparently straightforward cases a review of the notes of the
final admission will suffice, but care should be taken to look for any problems in the
delivery of healthcare including primary care where applicable.
External examination of the body. (This is mandatory if a cremation form is to be
completed).
A conversation with the NoK usually by telephone. See Appendix 3.
Any further investigations or conversations that the ME regards as necessary for a
specific case. Such investigations should not be allowed to delay certification of the
death without good cause.
6.6.5 The conversation with the NoK has two main functions:
To ensure that the next of kin understand the cause of death as entered on the
MCCD, if it is a coroner’s case, the cause of death will be explained to the NoK via
the coroner. It is not necessary for the NoK to agree the cause of death. Indeed,
objections to the cause of death on grounds of embarrassment rather than accuracy
should be politely rejected. However, the ME must consider any information provided
by NoK that relates to factual accuracy.
To ask about the quality of healthcare provided.
Where the case has been declared a serious incident, subsequent conversations
with the next of kin should take place via the SI investigator to fulfil duty of candour.
If the deceased had a learning disability inform the NoK that subsequent
conversations will take place with the LeDer lead who will contact them.
6.6.6 Conducting the conversation with the NoK:
The ME must follow the guidance on the conversation with the NoK in Appendix 3.
If asked to do so, the ME must inform the NoK how to make a formal complaint and
refer to PALS.
If the NoK appears to require bereavement support at this stage refer in the first
instance to the chaplaincy with their consent
If longer term support is required refer to the bereavement listening and support
service with their consent
If the NoK relays compliments to the care team these should be inputted onto the ME
Mortality Screening Form and reported back to the DGL/C and Speciality Mortality
lead for dissemination to the individuals concerned.
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Where possible the bereavement officer will visit the ward and relay the compliments
in the form of rapid audit feedback.
6.6.7 If it becomes clear that the ME will not be able to contact the certifying doctor, it is
acceptable to speak to another doctor who cared for the deceased.
6.6.8 If after several attempts the ME is unable to contact a member of the family, a
conversation with a doctor or nurse who cared for the deceased in their final illness may
be conducted for screening purposes. This may also be relayed by the Bereavement
Officer when visiting the ward team following a death.
6.6.9 Once the ME role is established at SMH screening of all BHT deaths can be rolled out
across other sites. This may involve a conversation between the ME and certifying doctor
over the phone as per policy guidance, an independent screen of the medical notes once
the notes have been scanned onto Evolve (within 72hrs) and then a telephone
conversation with the NoK in accordance with minimum criteria (see appendix 2.)
7.0 POSSIBLE OUTCOMES OF THE SCREENING PROCESS
7.1 If at any point during the screening process the ME becomes concerned that the coroner
ought to have been informed, referral to the Coroner’s office should take place. If the
telephone conversation supports referral, the MCCD must be cancelled and the certifying
doctor instructed to refer the death to the Coroner. If the MCCD has been collected by the
relatives, the ME must instruct the Bereavement Services office staff to contact the
Registrar and, if possible, the NoK, to inform them that the Coroner is reviewing the death.
7.2 If the ME screening the case concludes that the stated cause of death is incorrect (but
referral to the Coroner is nevertheless not required), the ME must decide if the error is
sufficiently severe to justify correction. In making this decision, thought should be given as
to whether the correction will modify how the Office for National Statistics will code the
cause of death (usually on the last item in part 1). If the MCCD has already been collected,
the error must be severe before considering recalling the certificate. In such cases the ME
must discuss the case with the Registrar’s Office.
7.3 The ME may decide to refer the case for more detailed retrospective case notes review.
This should be done when the ME concludes that such review would in probability provide
useful information about the quality of care and in accordance with the Learning from
Deaths Quality Standard Minimum Criteria¹ as stated on the BHT Medical Examiners’
Mortality Screening Form (see appendix 2). If it is evident that following the ME screen that
suboptimal care exists or there is a high probability of avoidable mortality a Datix must be
completed by the ME and a 72 hour report requested to decide whether a Serious Incident
investigation is required. This information should be sent by the ME via email to the SDU
Mortality lead, DGL/C and the divisional chief nurse who is accountable for ensuring a 72
HOURS: A commitment of 1 -2 PA will be required TERM: Permanent (Subject to yearly satisfactory performance) REPORTS TO: Associate Medical Director/ Lead ME ACCOUNTABLE TO: BHT Medical Director
JOB SUMMARY
BHT is introducing a Medical Examiner (ME) role as part of its Mortality Review Process. Whilst MEs
have been piloted in other areas of the NHS as part of proposed changes to the death certification
process, the BHT MEs will be working differently from these, working closely with Bereavement Services
and the speciality M&M Teams.
The BHT MEs will be appropriately trained, experienced Consultants who will undertake screening of all
in-hospital deaths in order to identify those cases which would benefit from further review by the relevant
Speciality M&M process to confirm whether or not the death was potentially avoidable and to take
forward associated learning and quality improvement actions.
BHT MEs will also complete Part 2 of the Cremation form, where applicable.
Medical Examiners will have professional independence in screening deaths but will be accountable to the Medical Director and will report to the Mortality Reduction Group and Lead ME for achieving agreed standards or levels of performance. Medical Examiners must avoid any potential conflicts of interest and must transfer to another ME the responsibility for the screening of any death in which they have had a personal, professional or fiduciary relationship with the deceased person, the next-of-kin or near relative of the deceased, or with the attending doctor who prepared the MCCD.
BHT Medical Examiners must be registered with a license to practise in the UK by the GMC. The principal responsibilities of the ME are to:
Screen the case records (paper and electronic) of patients who have died within BHT. The pilot phase will commence at Stoke Mandeville Hospital.
Support those doctors who call for medical advice on suspected natural causes of death when writing the Medical Certificate of Cause of Death (MCCD).
Be available to provide advice on the appropriate referral of cases to the coroner
Scrutinise the causes of deaths where an MCCD is to be or has been completed.
Contact the deceased’s ‘next of kin’ to explain the cause of death in a transparent, tactful and sympathetic manner, which respects different faith, cultural, ethnic and diversity considerations.
Ask the next of kin if they have any questions around the death certificate, the quality of care provided or any other matters relating to the patient’s death.
Complete the screening section of the BHT ME Mortality Screening Form and confirm whether further review by the relevant Speciality M&M is required, to include rationale as applicable.
Complete Part 2 of the Cremation Form, where applicable, to include speaking to relevant members of the clinical team and relatives and conducting an external examination of the body
Maintain comprehensive records of all deaths screened and provide input to analysis of mortality data
Liaise with other MEs to arrange cover for holidays and other periods of absence and also to ensure that there is no potential conflict of interest between the medical examiner and the death being scrutinised. In cases where the ME has been involved in the care of the patient they will not be able to complete the part 2 cremation form and so should not deal with such cases.;
Support the training of junior doctors in completion of MCCDs and provide feedback on accuracy of certification locally.
Comply with local protocols to ensure that each in-hospital death is screened in a way that is
robust, proportionate and consistent.
Exercise judgement in where to seek specialist advice in order to determine the appropriate level of scrutiny required
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Maintaining comprehensive records in an appropriate format
Take responsibility for own continuing professional development and take part in continuing
medical education activities, in accordance with any relevant standards for maintaining GMC
licence to practice and membership of any relevant professional body.
Be committed to the concept of lifelong learning and produce and maintain a Personal
Development Plan in agreement with your appraiser.
Attend relevant local, and national activities in order to maintain up to date knowledge and to
ensure compliance with legal and procedural requirements associated with the current processes
of certification, investigation (by coroners) and registration.
Participate in any relevant governance activities relating to the screening of in-hospital deaths
and confirmation of cause of death. This will include participating in audits and investigations
where appropriate and responding to complaints within the Trust’s expected timescale.
Be familiar with the role and function of the Coroner and able to present complex medical
information in such a way as to assist the Coroner decide whether to investigate a death about
which they have been notified.
The above list of duties is not exhaustive and may change subject to publication of national guidance
GENERAL DUTIES - BHT EMPLOYEE
1. Governance - To actively participate in governance activities to ensure that the highest
standards of care and business conduct are achieved 2. General Policies Procedures and Practices - To comply with all Trust policies, procedures and
practices and to be responsible for keeping up to date with any changes to these. 3. Access to Patients - In undertaking the duties outlined above the post holder will have access to
patients. This means that the post is exempt from the Rehabilitation of Offenders Act 1974 and all post holders must disclose any criminal conviction including those considered as spent under the Act. Post holders appointed to this will be required to consent to a check through the Criminal Records Bureau.
4. Registered Health Professionals -All persons appointed to the post are required to hold
registration with their appropriate professional Regulatory Body and to comply with their professional code of conduct. Evidence of on-going registration will be required.
5. Job Revision - This job description should be regarded as a guide to the duties required and is
not definitive or restrictive in any way. The duties of the post may be varied from time to time in response to changing circumstances. This job description does not form part of the contract of employment
6. Data Protection Act - All employees are subject to the requirements of the Data Protection Act
and must maintain strict confidentiality in respect of patient’s and staff’s records. 7. Equal Opportunities - All employees must comply with the Trust’s Equal Opportunities Policy
and must not discriminate on grounds of age, colour, race, nationality or ethnic origin, religion, belief, gender, marital status, sexuality, disability, trades union membership (or non-membership) or political affiliation, or any other grounds which cannot be shown to be justifiable.
8. Location - In order to ensure the Trust’s ability to respond to changes in the needs of the
service, after appropriate consultation and discussion with you (including consideration of personal circumstances current skills, abilities and career development) the Trust may make a
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change to your location, duties and responsibilities that are deemed reasonable in the circumstances.
Your normal place of work will be as discussed at interview but you may be required to work in other locations of the Trust. The pilot will commence at Stoke Mandeville Hospital.
Acknowledgements
Grateful thanks to University Hospitals of Leicester for sharing this job description which has been
revised in accordance with Buckinghamshire Healthcare NHS Trust (BHT) mortality review process.
Thanks are also extended to Professor Peter Furness Lead Medical Examiner for England for his
expertise and invaluable advice to enable introduction of the medical examiner role at BHT.
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Person specification: Medical Examiner
Essential Desirable
Qualifications
- Medical degree. - GMC licence to practise. - Satisfactory on going yearly appraisal - Continuing professional development - Successful completion of the approved
components of the national on-line training curriculum prior to undertaking case record reviews as a BHT Medical Examiner
- No current performance issue
Experience - Currently practicing at consultant level.
- Registered as a medical practitioner with a license to practice
- Experience of undertaking clinical case note reviews as part of Mortality and Morbidity or Serious Incident process
- Commitment to maintain knowledge and keep skills up to date.
- Ability to act proportionately and report sub-standard clinical and organisational performance to relevant colleagues to protect patients and to identify good practice and ensure the spread of knowledge amongst relevant colleagues
- Experience of applying principles of Quality Improvement.
- Chair of Speciality Mortality and Morbidity or Audit Group
- Part 2 Cremation Form Completion process
Knowledge Working knowledge of practice in a healthcare environment, Up to date knowledge of clinical causes of death, together with death certification requirements and processes. Ability to distinguish between natural and unnatural causes of death and when death must be reported to, and investigated by, a coroner. Awareness of equality and diversity issues within the community and a demonstrable ability to understand the requirements of diverse faith groups Knowledge of clinical governance systems as they affect the work of professionals and organisations.
Detailed knowledge of the relevant legislation and processes which apply to:
- coroners; - registering deaths; - cremations and burials
Knowledge of legal framework and relevant jurisdiction relating to the process of death certification.
Skills Good written communication skills, including the ability to summarise clearly and accurately. Good oral communication skills, including active listening skills, the ability to understand and summarise a discussion, ask appropriate questions, provide constructive challenge and
IT competent, for the purposes of efficient screening of in-hospital deaths
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Essential Desirable
give effective feedback. Ability to communicate effectively and with sensitivity with the relatives or representatives of the deceased when explaining the cause of death and to communicate with the bereaved of all faiths and communities in a sensitive and understanding manner. Ability to demonstrate transparency when explaining cause of death to bereaved families and make it easier to raise concerns. Ability to manage an information-based process under tight timescales. Ability to work within own team and closely with people in other disciplines Ability to assist or deliver training to enhance skills within the ME’s team and junior doctors in the process of death certification. Ability to identify available data sources to support detection and analysis of concerns and to recognise gaps in available knowledge.
Attributes Excellent personal integrity, personal effectiveness and self-awareness. Able to work independently and autonomously and manage own workload. Able to make timely and informed decisions. Demonstrates a commitment to and focus on quality. Able to work effectively in a team. Good working relationships and credibility with professional colleagues and relevant stakeholders. Good management skills - able to demonstrate effective and efficient working practices. Ability to put in place appropriate reporting, information sharing and feedback mechanisms
Promotes high standards to consistently improve patient outcomes.
Significant commitment to on-going personal education and development. Uses evidence to make improvements.
Acknowledgement
Grateful thanks to University Hospitals of Leicester for sharing this personal specification which has
been revised in accordance with Buckinghamshire Healthcare NHS Trust (BHT) mortality review
process.
Thanks are also extended to Professor Peter Furness Lead Medical Examiner for England for his
expertise and invaluable advice to enable introduction of the medical examiner role at BHT.
BHT Adult Mortality Review Process/BHT Reference No 215/Version 1.0 Issue No 1.0 Final Sept 2017
PART A: PATIENT & DEATH CERTIFICATION DETAILS - Adults > 18 years only
Patient’s Name: Patient’s MRN Number:
DOB: Sex: Appointment for Cert Pick-up:
Next Of Kin (name and relationship to deceased): Contact Numbers:
Admission Date: Em / Elec
Admission
Date of Death:
Allocated Consultant:
Last Ward/Unit:
Last Specialty:
In / Out of
Hospital Death
Religion (If Known):
Datix? Yes / No
MEDICAL EXAMINER PROCESS – PLEASE ANSWER FOR ALL DEATHS
Date of ME: Name of ME:
DNA CPR
Yes/ No
Cardiac Arrest call
Yes / No
Learning Disabilities
Yes/ No
Severe Mental Illness and/or Safe Guarding
Yes/ No Maternal
Death Yes/ No
Yes/No If yes, details and who spoken to (where applicable)
ME spoken to Certifying Doctor? Part 2 Cremation form completed? External Examination of the body by ME? Clinical records* reviewed by the ME? *To include both paper and electronic
Has the ME spoken to the relatives?
CORONER / REGISTRAR CONSIDERATIONS
Is this a Coroner’s Case? Referred Definitely Not
Why?
Email to Registrar Yes* / No* *Details, as applicable
DEATH CERTIFICATION
1a. 1b.
1c. 1d.
2.
CoD & Discussion with ME documented in patient’s case notes? To include main condition treated during hospital stay plus
co-morbidities for coders
Yes/ No
Proposed Cause of Death accepted
Yes/ No
Cause of Death modified by discussion with ME
Yes/ No
Replacement death certificate required
Yes/ No
Final Certificate if changed or replaced
1a. 1b.
1c. 1d.
2.
BHT Medical Examiners’ Mortality Screening Form
PILOT
APPENDIX 2
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PART B – SCREENING:
On reviewing the whole case, in your opinion was there evidence of the following. If yes, please indicate during which phase
of care and provide details in ME Case Note Screening Section below
On Admis-sion
Ongoing Care
Procedure related
End of Life / Discharge
Outside of BHT
Timeline issues eg delays or omissions in – diagnosis, investigations, delivery of care, treatment, care bundles (sepsis, AKI) etc.
Poor Communication
To include communication / clinical handover between clinicians, patients or family
Inadequate Monitoring
Failure to recognise or take appropriate action on ‘alerts’ e.g. NEWS >5, abnormal test results
End of Life issues
DNACPR not appropriately considered prior to cardiac arrest, DNACPR invalid or not followed; No TEP
Inadequate End of Life or palliative care; Lack of End of life Care Plan
Nursing care issues
Where not covered above (eg. left in wet bed, help with feeding)
Triggers / Risk Factors
eg. New DVT, Pressure Ulcer, Allergic reaction, Hospital Acquired Infection, Wound infection, Hypoglycaemia, High INR, Cardiac Arrest
NoK Concerns Where not covered above or about care provided by other organisations
Excellent Report Was the care delivered excellent and in which phases of care- this should include compliments from NoK
In your judgement, is there a need for feedback, learning or actions to be taken?
a. No feedback, learning or actions to be taken or feedback required ☐→SCREENING COMPLETED (Category 1)
b. Yes at least slight need for learning or actions or feedback to clinical team ☐→ GO TO SECTION C BELOW
PART C – FURTHER ACTION please complete all sections carefully so M&M team can action without delay:
IDENTIFIED FROM: NOTES OR CERTIFYING DOCTOR RELATIVES
PLEASE ENSURE IT IS CLEAR WHETHER SJR IS REQUIRED OR NOT (tick all applicable)
TYPE OF FEEDBACK / ACTION ✓ SPECIALTY / CLINICAL TEAM / DISCIPLINE
RCP SJR by Specialty M&M
Specialty to review and discuss case or to consider need for SJR
If ME unsure that SJR required - make clear why ME not referred directly for SJR.
Bereavement Support (please indicate if you think needs urgent f/up or routine (i.e. 6 weeks post death)
Clinical Team feedback Yes No This includes excellent reporting in the form of rapid audit feedback
Learning disability, Mental Health, State detention, Safe guarding, Primary Care (Circle) Other……….
M & M review using SJR is still beneficial for departmental learning
All paediatric deaths are referred to the CDOP lead as per BHT mortality review policy
DETAILS OF REASONS FOR SJR, F/U OR FEEDBACK TO BE GIVEN
ME Case Note Screening Comments
Relatives’ Comments (please make clear if positive or negative feedback)
WHILST NOT ALL CASES WILL REQUIRE FURTHER ACTION, ME COMMENTS / RELATIVES FEEDBACK WOULD STILL BE APPRECIATED
APPENDIX 2 CONTINUED
BHT Adult Mortality Review Process/BHT Reference No 215/Version 1.0 Issue No 1.0 Final Sept 2017
APPENDIX 3
PILOT PROFORMA FOR MEDICAL EXAMINER CONVERSATION WITH BEREAVED
FAMILY/CARER
Conversations between Medical Examiners and bereaved relatives; Some suggestions.
Medical examiners will each develop their own style. The following are merely notes to help you to do that, and to help ensure that the key elements are covered.
1. Confirm who you are speaking to. Hello, is that ………….. (name of bereaved)? Or Hello, may I speak to ……………….. (name of bereaved)?
2. Introduce yourself and say why you are calling. My name is Dr ….. [your name]. I’m calling from the Bereavement Office at Buckinghamshire Healthcare NHS Trust about the recent death of …… (name of patient) who I understand was your father / brother/ son etc. (If the relationship is not clear use ‘I have been given your name as the next of kin’. Getting the relationship wrong can cause offence).
3. By all means offer condolences or sympathy. Something like ‘Please accept my condolences on your loss’. But it’s probably not wise to use pleasantries such as ‘How are you?’. They’ve just been bereaved and in all probability will be feeling awful. It’s not your job to deliver a lengthy counselling session. Explain why you are calling: This is a routine call which we make after anyone has died in Buckinghamshire Healthcare NHS trust (name hospital) for two main reasons.
4. Ask the first main question. First I want to go through with you what the doctor who certified the death has put on the death certificate. It says: if this was a coroner’s case the coroner will explain cause of death. State what's on the death certificate, including the links such as ‘due to’. Then ask ‘Does that make sense to you?’ Or perhaps ‘That’s a lot of medical jargon. Do you need an explanation?’.
5. Explain the cause of death if invited.
6. Ask the second main question. Second; whenever someone dies at Buckinghamshire Healthcare NHS Trust we always ask about the quality of healthcare. Do you think there is any aspect of the healthcare that might have been better?
As (patient name) had a learning disability the learning disability liaison nurse will be in contact with you in the near future
7. Listen, and if necessary sympathise, explain and assist.
8. Ask any supplementary questions. Such as: The cause of death involves problems with the lungs, so I need to know whether Mr Smith was ever employed in a job that has a risk of causing lung disease?
9. Ask whether there are any other questions. If any concerns ask if you can arrange for the Bereavement Listening and Support Service to phone them to discuss more fully. If they need immediate assistance refer to Chaplaincy.
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10. Identify sources of further information and support if it seems appropriate. Don’t try to be a bereavement counsellor, advise about the Bereavement Support and Listening Service and ask if they would like them to phone.
11. Draw the conversation to a close. Explain that the Bereavement Office staff will be in contact, if they have not been in contact already.
Acknowledgements
Grateful thanks to University Hospitals of Leicester for sharing this guide to conversations between
medical examiners and bereaved families which has been revised in accordance with
Thanks are also extended to Professor Peter Furness Lead Medical Examiner for England for his
expertise and invaluable advice to enable introduction of the medical examiner role at BHT.
Page 33 of 45
APPENDIX 4 SPECIALITY MORTALITY AND MORBIDITY SPECIALITY MEETINGS,
OUTPUT AND LINES OF ACCOUNTABILITY
1.1 A Model of the process is described here which may be adapted by each SDU/Directorate provided
the RCP SJR reviews and outputs are undertaken/met. Compliance with this process is reported
via the mortality portal web page which networks with Qlikview to ensure reporting and a BHT
mortality dashboard in accordance with national requirements¹.
1.2 Each SDU should conduct a first stage SJR review of all deaths selected by the medical examiner.
Deaths are attributed to the consultant by the ME. If the attribution is incorrect the death may be
reallocated by the Divisional Mortality Lead/ Coordinator (DGL/C) with support of the SDU
leads/division chair as necessary. When the independent screen by the medical examiner has
taken place and the death has been categorised as expected (category 1) and no further learning is
identified the bereavement officer will update the chapel drive and no further action is required.
1.3 All unexpected deaths or a classification of suboptimal care (category 2 or 3) require a first stage
review using RCP SJR methodology. The initial RCCR can be conducted by a junior doctor or
nurse that presents to M & M with the RCP SJR methodology being completed at the meeting by
ST3 or above. This must be an independent doctor that has not been involved in the care of the
patient but can be from the same speciality. The RCP SJR methodology should be completed with
the associated guidance to include all phases of care where applicable with a judgement score and
collateral evidence to support. The RCP SJR is structured to identify good care as well as care that
can be improved. Where a rating of excellent care has been given this should be reported back to
the care team involved in the form of rapid audit feedback. This information should also be captured
at M & M via the Datix RCP SJR portal so themes can be identified within specialities and across
divisions.
1.4 Where a rating of poor or very poor is given at M & M in any phase of care a further independent
second stage review must be conducted by the SE Panel and a datix written at M & M. The Deputy
Chief Nurse for quality who chairs the SE panel must be contacted by email with collateral
information and informed of the need for second stage review and will henceforth co-ordinate cases
as required. The divisional chief nurse is accountable for ensuring a 72hr report is written to
determine if SI investigation is indicated.
1.5 If at M & M the death was deemed unavoidable score 4-6 according to RCP SJR ratings then an
avoidability rating can be given. All subsequent decisions should be relayed by the SDU Mortality
lead to the DGL/C who then uploads the data to the mortality portal.
1.6 The SE panel will consist of the lead ME and Lead Nurse for Quality Improvement in conjunction
with SE group members to be quorum. The SE panel will meet fortnightly to present and discuss
cases and provide a second stage RCP SJR review and avoidability rating. The consultant involved
in the patients care can attend the SE panel to contribute to the case as required. Any member of
the SE panel can present the case but an overall judgement will be made by the group. All output
from this meeting should be feedback to the SDU Mortality lead via email and the DGC/L so the
mortality portal can be updated accordingly. Actions from the SE panel should be disseminated to
the SDU Mortality leads and DGL/Cs who are responsible for identifying leads and for
dissemination of learning. All avoidable deaths score 1-3 should be datixed discussed at MRG and
be subject to SI investigation if this has not already been the case.
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1.7 It is encouraged that M & M meetings should have a multi-disciplinary focus with senior nurses and
allied health care professionals attending where able. Senior nurses and allied health care
professionals can then contribute to RCCR and be involved in subsequent action plans and quality
improvements.
1.8 Where learning from deaths has been identified this must be catalogued into an action plan with
associate leads and time frames to encourage completion. These action plans should be revisited
on a monthly basis as a standing item at M & M and minuted accordingly. Where themes are
identified these should be feed into the trust workstreams to ensure a co-ordinated approach and
dissemination of trust wide learning. Responsibility for action plans and dissemination of learning
rests with the SDU Mortality lead with the DGC/L using an action plan tracker to monitor
compliance.
1.9 An M & M administrator will work with the lead nurse to ensure data accuracy, monitoring and
outcomes from mortality review are captured and learning from deaths evidenced.
1.10 SDU leads should also triangulate examples of suboptimal care with other SDU performance risks.
1.11 The SDU/Directorate summaries are synthesised into a Divisional overview on the Qlikview for the
Divisional Boards and are included on their dashboards. The divisional governance
lead/coordinator will take an overview of issues arising from first stage and second stage reviews to
identify themes to be presented to the Divisional Board and Mortality Reduction Group.
1.12 Learning from Deaths should be a standing item at Divisional performance meetings.
2.0. Divisional Boards
The role of the Divisional board is to:
Receive the monthly Divisional overview from the DGL/C
Seek assurance for SDU/Directorate leads that action plans are developed for avoidable deaths.
Hold relevant individuals to account to ensure delivery of action plans.
Triangulate mortality trends with divisional performance risks. Report performance on quality template
and to Trust Board via Quality Committee.
Discuss at bi-monthly performance review.
Undertake duty of candour and inform relatives about potentially avoidable deaths.
3.0 Mortality Reduction Group (MRG)
3.1 The aim of this multi-disciplinary group is to oversee and progress a programme of work which leads towards a reduction in trust mortality as measured through national measures (SHMI and HSMR). 3.2 Objectives
To monitor overall trust mortality using HSMR and SHMI
To develop a diagnosis group signal monitoring process
To oversee the investigation of mortality alerts received from national bodies such as CQC, Dr Foster etc
To receive reports on the SDU reviews of all deaths and to support those reviews
To identify and spread learning from the SDU mortality reviews and the SE group particularly when sub-optimal care has been recognised
To oversee the actions taken when an avoidable death has been recognised, including Duty of Candour
To receive reports on mortality trends in specialties triangulated with complaints/SIs and patient feedback
To review national surgical outcomes data suggesting action where needed
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To receive, discuss and make recommendations on regular collated reports on key audits which influence mortality such as NEWS scores and responses, fluid balance, sepsis, pneumonia, heart failure, renal failure, medical admissions to ICU for sub-optimal care, time to consultant review – emergency admissions and cardiac arrests and peri-arrests
3.3 Accountability – To the Trust Board via the Quality Committee
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APPENDIX 5 RCP SJR METHODOLOGY FOR RCCR- EXAMPLE
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APPENDIX 6 GUIDANCE ON HOW TO COMPLETE RCP SJR REVIEW
Link to…………………………………………………………………………………
APPENDIX 7 MORTALITY DATA
All staff with access to Medway have a responsibility to ensure accurate data input in accordance
with data protection and information governance trust policy
All doctors caring for the deceased have a responsibility to complete the GP notification of death
form on DOCGEN to ensure timely notification
An identified member of the ward team is responsible for completing the Death Notification Form
for the bereavement office and placing it on top of the medical notes
The certifying doctor is responsible for documenting cause of death in the medical notes following
discussion with ME including primary diagnosis for coders.
The bereavement office is responsible for maintaining the chapel drive including outcome from
ME independent screen and referral for speciality deaths.
The DGL/C is responsible for liaising with the medical examiner as required and the SDU
Mortality lead and ensures all data is inputted correctly onto the mortality portal. The medical
examiner mortality screening form is sent to the SDU Mortality lead and DGC/L and a copy kept
in the bereavement office for auditing purposes.
All data output from the Speciality M & M is relayed to the divisional DGC/L. This data will be
inputted into the mortality portal which networks with Qlikview for divisional and speciality
reporting. The DGL/C will support SDU Mortality leads to produce monthly SDU summaries with
the SDU lead for review at SDU meetings.
Data from RCP SJR will be inputted into a stand-alone Datix platform. This will be piloted and
training given by RCP.
Themes can be extracted for departmental, divisional and trust wide learning. All DGC/Ls should
be able to run reports and extract themes in conjunction with the SDU clinical governance leads.
The DGL/Cs will also maintain an action plan tracker to monitor compliance with actions from M
& M and the SE group. Datix handlers should sign off investigations once complete.
A BHT mortality dashboard is accessible via Qlikview in accordance with the quality standard
learning from deaths national requirements¹. Mortality data should be presented at MRG for
auditing purposes, identifying trends and monitoring compliance.
Mortality data will be used to inform future quality improvements through departmental and BHT
work streams. A quality improvement administrator will work with the lead nurse to ensure data
accuracy, monitoring and outcomes from mortality review are captured and learning from deaths
evidenced.
Lessons learnt and case reviews to disseminate learning from deaths should be disseminated to
front line staff and at forums such as, departmental meetings, lessons learnt and academic half
days and via communications.
NMCRR data
collection sheet England_0_0.pdf
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APPENDIX 8 FLOWCHART BHT ADULT MORTALITY REVIEW PROCESS