Learning from Inpatient Deaths to Drive Improvements in Patient Care

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In recent years, improving patient safety has become a major part of the agenda for the NHS.

NHS Resolution’s 2019/20 Annual Report [1] provides useful context to understand the impact on the sector of compromised patient safety:

• The annual cost of harm arising from clinical activity during 2019/20 covered by the Clinical Negligence Scheme for Trusts was £8.3 billion in 2019/20, reducing from £8.8 billion for 2018/19

• The provision for the liabilities arising from claims for all financial years covered by all NHS Resolution schemes has increased by £0.7 billion from £83.4 billion to £84.1 billion

• 11,682 new clinical claims and reported incidents were recorded in 2019/20

• Maternity claims remain the highest value area, representing 50% of the total value of all clinical negligence claims received, 69% of the incurred cost of harm and 72% of the total CNST provision

There is still much to do in the sector when improving patient safety and minimising patient harm. There is a need for healthcare professionals and organisations to really recognise their duty to develop systems that improve the quality of care and safety of patients.

Maximising patient safety requires the establishment of appropriate relationships between the clinical provider and patient that respect the personal and cultural needs of the patient. The pandemic has taught the sector the importance of transparent communication between the care provider and the patient to ensure the needs of the patients are met for them to feel safe in any given care context.

Moreover, much has been done in high-income countries to develop our own systems. As other countries look to us for inspiration, perhaps it is time to look inward and try to develop new ways of driving patient safety from the bones of existing care structures.

Learning from Inpatient Deaths to Drive Improvements in Patient Care

Reinforcing the assertion of learning from existing structures of care when striving to improve patient safety, we heard from Dr Dan Monnery. Dan is a Consultant in Palliative Medicine and Patient Safety Lead at the Clatterbridge Cancer Centre. They are also National Clinical Advisor for Enhanced Supportive Care [2].

The Clatterbridge Cancer Centre NHS Foundation Trust is one of the UK’s leading cancer centres providing specialist cancer treatment to a population of 2.4 million people across Cheshire, Merseyside, and the surrounding areas.

This graphic was provided by Dan and shows the gradual development of a mortality review process over the past decade, a journey the Clatterbridge Centre has had to adapt with over the years.

To look at the patients’ experience of care is pivotal. Palliative care providers must move away from looking at just the cause and effect of factors leading to a patient’s death and instead focus on what the care was like.

Mortality review meetings and peer discussion around mortality began to facilitate this new way of thinking but didn’t really come around until 2012. From 2018 onwards, Structured Judgment Reviews (SJRs) came into force and enabled doctors look at patient cases and patient journeys in a lot more detail. These gave professionals the opportunity to look closely at a patients experience of care.

Since 2019 the lessons arising from mortality review processes have been embedded back within the Directorate of Quality and Safety and fed back to ward quality and safety processes. Consequently, the people that deliver the care are those that are getting the information from the mortality reviews. They are then able to maximise patient safety through the acknowledgement of historical evidence.

The Phases of the Mortality Review Process

When embarking on a mortality review there are three main phases that contribute to painting an overall picture of the standard of care that the patient received in the lead up to their death.

Phase 1: The patient’s treating consultant reviews the care to see whether the treatment decisions were appropriate and whether they were backed by policy guidelines. Additionally, they seek to see what reflections can be drawn to understand what could have been done differently during the care.

Phase 2: A peer review or for inpatients a structured judgment review is carried out. These reviews ask additional questions about what the care of the patient was like but seeks the perspective of those who were not the primary care provider.

Phase 3: The final phase is the main Mortality Review Meeting which brings together evidence from phase 1 and phase 2 for discussion. One of the key things that have changed over the past 3 or 4 years is the tone of the meeting. It does not focus on cause and effect, but instead answers questions that have come up in phases 1 and 2. The role of the meeting is to reflect on what has happened during the care of the patient and what can be learned from it without casting blame on one party.

Casting the net wide

Dr Monnery explained that something that has proven effective in the process has been to take a broad look at the medical demographic of the deaths being reviewed. It is ensured that patients suffering a diverse set of conditions in the lead up to their death are thoroughly reviewed after their death. These types of patients include:

• All inpatient deaths

• All deaths within 30-day palliative chemo/radiotherapy

• All deaths in the 90 day post radical chemo/radiotherapy window

• All those who passed away with mental health illnesses as well as those with learning disabilities

• Those who died within the 100-day bone marrow transplant period

• Any patient under 18 years old

• Any death of a patient where a concern has been raised

• Equally any concern formally or informally from family of the deceased

Covering a broad demographic ensures that flaws in care do not go unnoticed. All types of care for all types of patients are covered in the reviews to ensure that the safety of future patients is maximised, and blind spots are checked.

Structured Judgement Reviews

The number of SJRs that have come back to the Mortality Review Meetings in Phase 3 has risen year on year.

Using SJRs, it is possible to tailor reviews around the local needs of the care provider. For the Clatterbridge Centre the SJRs include:

• A review of the care in the first 24 hours of inpatient admission
• A review of the ongoing care of the patient
• A look at any procedures including chemotherapy administration
• Reviewing end-of-life care
• An overall rating of the quality of care

Involving Families

Involving families and carers in the review process is key. At Clatterbridge Centre, a Day-After-Death Conversation has been put in place. The day after a patient dies, their relatives, friends and carers get the opportunity to sit down face to face or digitally with a care provider that they know and trust to talk about what their experience of care has been.

This conversation also serves as a debrief and is used to facilitate the right bereavement support for them. It allows palliative care providers to receive feedback and therefore to discover what they could do better for similar patients in the future.

The information given by the family of the deceased is then fed back into the SJRs and ultimately is fed into the mortality review meeting.

This has proven to be an effective way of triangulating all information on the patient. The information feeds into the planning of care, the audit schedule, and the patient experience group which all strive to improve patient safety. The checks and measures are therefore put into place to ensure that measures of care are consistently being improved.

Multi-Professional Engagement

There has been an increase in multi-professional engagement in mortality review meetings.

Historically, at the Clatterbridge Centre, the meetings used to involve a Quality Team, Clinical Oncologists and Medical Oncologists. They now include input from:

• Pharmacists

• Triage Teams

• Chemotherapy Nurses

• Palliative Nurses

• Matrons

• Inpatient Nurses

• Dieticians

• Junior Doctors

This cross-disciplinary communication offers differing perspectives on mortality that may not have been picked up on previously. Lessons learned from the mortality review meetings are shared via conferences with various healthcare professionals and fed into universal Patient Safety Bulletins to ensure that the cross-disciplinary sharing of information is accessible to those providing palliative care and advice.

Driving Quality Improvement

Dr Monnery shares some success stories in which the mortality review process has resulted in positive changes to patient care and safety.

The Clatterbridge Centre discovered better ways of administrating steroids in the treatment of laryngeal oedema. They also received feedback stating that they should provide additional support to better advise patients on the management of diabetes.

It was brought to the centre’s attention that there ought to be better communication with patients and the families of patients around do not attempt cardiopulmonary resuscitation (DNCPR) conversations. Additionally, they discovered new ways of detecting sepsis through the acquirement of multi-professional knowledge as well as ways to improve safety in discharge paperwork.

These are all things that benefit patient care. If historical processes of only investigating patient deaths that raise an eyebrow were still followed, then a lot of these developments in care would have been missed.

What Does it all Achieve?

The review procedures are in place to ultimately reduce treatment-related mortality. More importantly, it enables palliative care providers to improve the quality of their care going forward.

40% of patients with cancer will die from it, and although doctors cannot always change the outcome of death, they can change the journey for those who are facing it. Care can be made safer and more comfortable along the way for these patients through consistent vetting of care procedures.

[1] The NHS Resolution’s Annual report 2019/2020

[2] Monnery, Dan Dr. 2021.  Consultant in Palliative Medicine and Patient Safety Lead at the Clatterbridge Cancer Centre.