Buckinghamshire Healthcare NHS Trust Adult Mortality Review … · Page 2 of 45 Location:...

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

1.0 1.0 CQC report 2016 Learning,

Candour and Accountability.

https://www.cqc.org.uk/sites/d

efault/files/20161213-learning-

candour-accountability-full-

report.pdf

2016

1.0 1.0 In response to the quality standard

learning from deaths national

requirements 2017

https://www.england.nhs.uk/w

p-

content/uploads/2017/03/nqb-

national-guidance-learning-

from-deaths.pdf

2017

Associated documents

BHT

Ref

Title Location/Link

049 An

Organisation-

wide Policy

for the

Management

of Incidents

Including the

http://swanlive/sites/default/files/bht_pol_049_v4.4_rvw_07_2017.pdf

https://www.cqc.org.uk/sites/default/files/20161213-learning-candour-accountability-full-report.pdf




https://www.england.nhs.uk/wp-content/uploads/2017/03/nqb-national-guidance-learning-from-deaths.pdf





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Management

of Serious

Incidents

319 Bereavement:

Guidance and

Procedures

relating to

Adult Deaths

http://swanlive/sites/default/files/guideline_319.pdf

218

Deaths:

Completion of

Death

Certificates,

Role of

Cororner,

Post Mortems


408

Maternal

Death












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Contents

Section No

Title Page No

1 Introduction 6

2 Purpose 6

3 Definitions 6-9

4 The Policy 9

5 The role of the BHT Medical Examiner 9

5.1 Appointment, training and resourcing of Medical Examiners 9

6 Process following the death of a patient on the ward 10

6.1 Notification of death and identification of certifying doctor 10

6.2 Discussion between the certifying doctor and the ME 10-11

6.3 Outcome of the discussion between the certifying doctor and the ME 11

6.3.1 - referral to coroner 11

6.3.2 - it is agreed that the certifying doctor can complete the MCCD 12

6.4 Preparation for Screening and completion of Cremation Forms 12

6.5 Completion of Cremation Forms where applicable 12-13

6.6 Screening the case (including conversation with Next of Kin (NoK)) 13-14

7 Possible outcomes of the screening process 14-16

8 General notes about working practices (8.1-8.5) 16

8.6 Paediatric cremation forms 16

8.7 Fees for Part 2 Cremation Forms 16-17

8.8 Bereavement officer appointment with bereaved NoK or nominated representative

17

9 Lead Medical Examiner 17

10 Lead Nurse for Quality Improvement 18

11 Consultation process used to inform this policy 18-19

12 Proposed policy dissemination 19

13 Process for monitoring compliance 19-20

14 Review and Audit 20

15 Equality Impact Assessment 20-21

16 References 21

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17 Acknowledgements 21

Appendices

App 1 Medical Examiner Job Description/Person Specification 22

App 2 BHT Medical Examiner’s Mortality Screening Form 28

App 3 Proforma for Medical Examiner conversation with Bereaved Family/Carer 30

App 4 Speciality mortality and morbidity speciality meetings, output and lines of

accountability

32

App 5 RCP SJR Methodology for RCCR 34

App 6 Guidance on how to complete RCP SJR review

NMCRR data

collection sheet England_0_0.pdf

42

App 7 Mortality Data 42

App 8 BHT Flowchart Adult Mortality Review Process 43

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1. INTRODUCTION

In response to the publication of the Learning from Deaths quality standard¹ 2017

Buckinghamshire Healthcare NHS Trust (BHT) has revised the current mortality review process

to align with national requirements. The CQC report Duty, Learning and Candour² outlined the

case for change to build standardisation and uniformity into the mortality process locally and

nationally. Greater emphasis should be placed on independent review of all deaths, to promote

objectivity and external scrutiny, with improved engagement with bereaved families/carers to

ensure learning from deaths enables and informs quality improvements.

2. PURPOSE

This policy will outline the agreed process for mortality review at BHT in accord with national

guidance. The policy will commence by outlining a new model of working to incorporate the role

of medical examiner (ME) to independently screen all deaths. The benefits of medical

examiners have been clearly evidenced³ and include increased accuracy in death certification,

close relationships with the coroner, a reduced rejection rate from the local registry, increased

support and training for junior doctors, greater engagement with bereaved families/carers and a

greater emphasis on learning from deaths. This policy will describe the mortality review process

from ME through to speciality Mortality and Morbidity (M & M) to ensure learning from deaths

within each SDU, Division and Trust wide. A recognised methodology for retrospective case

note review at M & M will assist in standardisation and collating themes to focus learning from

deaths in the future. This will feed into current work streams including Serious Incident (SI)

investigations to support quality and safety for BHT patients and trust wide learning. The target

audience for this policy includes all staff involved in the care of the deceased and bereaved

families/carers. It is also relevant to all staff involved in mortality review and subsequent quality

improvements.

3. DEFINITIONS

This policy will describe the process of mortality review following a death in hospital or where a

patient has expressed a wish to die in the community within 72hrs of hospital discharge.

Adult > 18 years old

Avoidable Mortality BHT will be adopting the RCP SJR definitions as recommended by

NHS Improvement. Avoidability ratings can be given during M & M

at first stage review. If a rating of poor or very poor in any phase of

care is given at M & M the case requires second stage review by

the SE panel who will then give an avoidability rating.

Bereaved

families/carers

The deceased nominated next of kin (NoK) or an agreed

representative.

Bereavement Support Where immediate support is required the ward team or

bereavement officer may contact the chaplaincy. Where long term

support is required this will be in the form of the bereavement and

listening support service

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CDOP Child Death Overview Panel

Chapel Drive A shared drive for mortality data

Coroner Officer whose chief function is to investigate by inquest, or before a

jury, any death not clearly resulting from natural causes.

Counselling If counselling is required this should be arranged via the general

practitioner or a certified counsellor.

Crem Part 2 Form Part 2 of the cremation form to be completed by the medical

examiner.

DGL/C Directorate Governance Lead/Co-ordinator

End of Life (EoL) Care End of life care helps all those with advanced, progressive,

incurable illness to live as well as possible until they die. It enables

the supportive and palliative care needs of both patient and family

to be identified and met throughout the last phase of life and into

bereavement. It includes management of pain and other symptoms

and provision of psychological, social, spiritual and practical

support. National Council for Palliative Care (2006) The End of Life

Care Strategy (2008)

First Stage Review Following initial independent screen a proportion of deaths will

require first stage case note review using the RCP SJR

methodology. This will be completed by an ST3 or above at

speciality M & M.

GP General Practitioner

Independent Screen This is the initial screen of the death against minimum criteria as

outlined in the quality standard Learning from Deaths¹.

Independent screen is conducted by a medical examiner that has

not been involved in the patient’s care but can be from the same

speciality.

LeDer Programme Learning Disabilities Mortality Review (LeDeR) Programme

See http://www.bristol.ac.uk/sps/leder/

http://www.bristol.ac.uk/sps/leder/

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Lead ME Lead Medical Examiner responsible for the recruitment and

selection of MEs, leadership, training and monitoring of the ME

service. Academic Health Science Network Regional clinical lead,

core member of the SE panel and CCG county-wide mortality

group. The Lead ME will ensure a robust process of mortality

review in accordance with this policy to include learning from

deaths across BHT and externally across organisations with

support from the Lead Nurse.

MCCD Medical Certificate of Cause of Death

Medical Examiner (ME) This role is not the same as the proposed national role. The ME

role in BHT includes advising and supporting certifying doctors,

screening deaths for review, liaising with the coroner as required,

engaging with bereaved families/carers and completing part 2

cremation forms.

Medical Examiners’

Mortality Screening

Form

The form used by the ME to conduct an independent screen of all

deaths- see appendix 2

Mortality data Any information relating to the deceased

M & M Morbidity and Mortality Meetings

MRG Mortality Reduction Group

Notice of Death Form Stoke Mandeville - yellow/orange A5 form. Amersham (including

Waterside and Chartridge Wards) and Wycombe – A4 form. Not in

use at other community sites. With patient’s name, address, ward,

date of death, doctor’s name, GP, next of kin details completed by

the ward team.

RCRR Retrospective Case record review includes a structured review of

the medical and nursing documentation and any other relevant

information pertaining to the case ie radiology, pathology results

RCP SJR RCCR The Royal College of Physicians Structured Judgement Review

methodology for retrospective case note review

Registrar Registrars collect and record details of all deaths and are

employed by the local authority.

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SE Panel The Serious Event Panel consisting of the lead medical examiner,

members of the serious event group and the lead nurse for quality

improvement as quorum to conduct a second stage review of

deaths in accordance with RCP SJR and determine an avoidability

rating.

Second Stage Review This is conducted by the SE panel who will conduct a second

independent review of the death using RCP SJR methodology and

decide upon an avoidability rating.

Severe Mental Illness In relation to this requirement, there is currently no single agreed

definition of which conditions/criteria would constitute Severe

Mental Illness. The term is generally restricted to the psychoses,

including schizophrenia, bipolar disorder, delusional disorder,

unipolar depressive psychosis and schizoaffective disorder. It

should also include all patients detained under the mental health

act (1983) see https://improvement.nhs.uk/resources/learning-

deaths-nhs/#h2-mental-health

ST3 A registered medical practitioner working within BHT working in the

capacity of a specialty trainee year 3 (ST3) who is registered with

the general medical council.

4. THE POLICY

This policy aims to ensure consistent and high quality independent screening of all deaths.

Screening and where applicable first and second stages RCRR takes place to learn lessons and

help to ensure the highest possible quality of care for all patients. The process for engagement

with bereaved families/carers will be described including a pathway for bereavement support

where required. Learning from deaths is aimed at quality improvements throughout the patient

pathway including end of life. The focus is on Trust wide and regional learning amongst multi-

agencies where necessary.

5. THE ROLE OF THE BHT MEDICAL EXAMINER

5.1 Appointment, training and resourcing of Medical Examiners

5.1.1 Part-time Medical Examiners will be recruited from experienced BHT Consultants.

Recently retired consultants will be considered if they maintain a GMC Licence to

practise. This role will be included in job plans and if recruiting retired consultants as an

honorary contract.

5.1.2 Recruitment into the ME role will be following a selection and recruitment process led by

the lead ME.

5.1.3 A medical examiner job description and person specification has been provided (see

appendix 1)

5.1.4 A face to face training session will be provided for MEs

5.1.5 MEs will be required to complete a subset of online training before taking up the role .

This can be found at http://www.e-lfh.org.uk/programmes/medical-examiner/

https://improvement.nhs.uk/resources/learning-deaths-nhs/#h2-mental-health

https://improvement.nhs.uk/resources/learning-deaths-nhs/#h2-mental-health

http://www.e-lfh.org.uk/programmes/medical-examiner/

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5.1.6 The Bereavement Officers will support and assist the new ME process supported by the

lead ME.

5.1.7 A rota of MEs will be produced and maintained by the Lead ME.

5.1.8 The Lead ME will ensure adequate MEs are available to fill the rota

5.1.9 Desk space, IT equipment and a designated phone will be available in the Bereavement

Office for the ME.

6.0 PROCESS FOLLOWING THE DEATH OF A PATIENT ON THE WARD

6.1 Notification of death and identification of certifying doctor

6.1.1 The ward staff should ring the Bereavement Office to inform them of a death and leave a

message on the answer phone if out of hours in accordance with

http://swanlive/sites/default/files/guideline_319.pdf. The Bereavement Officer will also

attend the mortuary each day at 0900 to receive notification of in-hospital deaths.

6.1.2 On notification the bereavement officer will collect the medical notes from the mortuary

including the Notice of Death Form with all relevant details completed

6.1.3 The Bereavement Officer will identify and contact a doctor who is in a position to be able

to certify the death or complete the referral to the coroner; this should be done by visiting

the ward where the death occurred to engage with the ward team and identify any

issues. NB The ward team at handover should identify a doctor available to complete the

Medical Certificate of Cause of Death (MCCD) and refer to the coroner as required.

6.1.4 The doctor is instructed to attend the Bereavement Office to complete an MCCD or

complete the referral to the Coroner. The certifying doctor should attend the

Bereavement Office during ME attendance hours each Mon –Friday afternoon. If the

death requires referral to the coroner this should be done early in the day to avoid delay.

6.1.5 Doctors should be familiar with the list of exclusions preventing initial completion of the

MCCD and necessitating referral to the Coroner. A list is kept in the Bereavement

Office see http://swanlive/sites/default/files/guideline_319.pdf

6.1.6 If the certifying doctor needs to refer the death to the Coroner, then the certifying doctor

is instructed to complete the coroner’s referral form; this should be completed in full and

sent to the coroner by fax early in the day see

http://swanlive/sites/default/files/guideline_319.pdf . The coroner’s office will contact the

doctor if any collateral information is required.

6.1.7 Cases that have been referred to and accepted by the coroner will automatically be

subject to retrospective case notes review and will be screened by a ME.

6.1.8 The doctor is advised before completing an MCCD to discuss the case with a ME and if

referral to the coroner is not required to agree the cause of death for the MCCD.

6.1.9 The doctor must complete a death notification form via DOCGEN to inform the GP if not

already completed. This ensures timely notification of death to the GP.

6.2 Discussion between the certifying doctor and the ME

6.2.1 The ME can be contacted by telephone or preferably by attending the Bereavement

Office at an agreed time (see above). The bereavement officer can advise the doctor on

how to contact the duty ME (SMH (110) 6646).




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6.2.2 If a doctor who is in a position to certify a death refuses to do so promptly by the next

working day they may be reminded that completing a death certificate is a statutory duty

of a doctor, so refusal without good cause is unlawful unless another doctor who was

more closely involved in the care of the deceased is readily available to complete the

certification.

6.2.3 If the ME is unsure whether the coroner would wish to investigate the case, the ME

should instruct the certifying doctor to complete the coroner’s referral form and send to

the coroner by fax. Deaths can be reported to the Coroner’s Office on 01494 475505,

during office hours Monday to Friday. During the weekend or bank holidays, for

emergency deaths only, call Thames Valley Police on 101. At SMH, in the first instance

please contact the Bereavement Office on ext. (110) 6646.

6.2.4 In rare cases the ME may need to obtain advice; for example, from other MEs or from

other specialists, such as microbiology in the case of healthcare-associated infections.

6.2.5 A list of ME contact numbers will be available in the Bereavement Office.

6.2.6 In order to complete the discussion the certifying doctor should always discuss the case

with the consultant involved in the care of the deceased before a decision can be made

with the ME.

6.2.7 Where the cause of death has been agreed and a MCCD completed this should be

documented in the deceased medical notes including the main condition treated during

the hospital stay plus co-morbidities for coders.

6.3 Outcome of the discussion between the certifying doctor and the ME

6.3.1 Referral to Coroner

If not already achieved, the certifying doctor is instructed to complete a form for

referring the death to the coroner.

At the discretion of the Bereavement office and with advice from the ME the certifying

doctor may be invited to complete an MCCD while the coroner’s decision is awaited.

The MCCD must not be released to the relatives unless the Coroner authorises its

release.

If the certifying doctor needs to change the cause of death on the MCCD after

discussion with the coroner the following applies:

If the changes are minor the certifying doctor will be asked to return to the office

and make changes to the MCCD and the counterfoil in the normal way.

If the changes are too great, the bereavement officer must write ‘CANCELLED’

across the face of the MCCD and its counterfoil and staple the cancelled certificate

to the counterfoil. They will then arrange for the doctor to come and complete a

new MCCD

If the coroner accepts the case for investigation, the bereavement office staff must

write ‘CANCELLED’ across the face of the MCCD and its counterfoil and staple

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the cancelled certificate to the counterfoil. They will also inform the certifying

doctor.

If the coroner instructs that an MCCD can be completed, but the certifying doctor

has not completed an MCCD, the following options are pursued.

Once the Coroner’s office has agreed a cause of death, the certifying doctor should

issue the MCCD with the wording agreed with the Coroner’s office.

The Coroner’s office will already have contacted the NoK of the deceased and

discussed the agreed cause of death

The Coroner’s office will have already contacted the Registrar’s office stating the

cause of death that it is anticipated will be on the MCCD.

The Coroner's cause of death and the MCCD must match if the Registrar is to

register the death without further discussion and delay.

When a patient is discharged home to die in accordance with their wishes, the

coroner may contact the certifying doctor when a MCCD is required. This will be

agreed on a case by case basis when the GP is unable to issue the MCCD.

6.3.2 It is agreed that the certifying doctor can complete the MCCD

The certifying doctor completes an MCCD with the cause of death as agreed

between the ME and the certifying doctor and if required completes the part 1

cremation form.

Ultimately, what goes on the certificate is the responsibility of the doctor who signs

the certificate. The ME can give advice but cannot dictate what is written.

If there is any possibility that such a (natural) cause of death might cause concern to

the Registrar, the ME must immediately email an explanation to the Registrar at

[email protected]

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

hour report is completed see

http://swanlive/sites/default/files/bht_pol_049_v4.4_rvw_07_2017.pdf

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7.4 The ME may decide NOT 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

NOT provide useful information about the quality of care.

7.5 MEs should aim to refer approximately 20% of deaths for first stage review in accordance

with RCP recommendations for SJR.

7.6 For each case that is screened the BHT Medical Examiners’ Mortality Screening Form must

be completed by the ME. Any complaints or compliments from the NoK must also be

recorded on the form.

7.7 The BHT Medical Examiners’ Mortality Screening Form is sent to the SDU Mortality lead

and DGL/C for further action as appropriate. A copy is kept in the bereavement office for

auditing purposes. The chapel drive should be updated by the bereavement officer to

indicate that an independent review has taken place and subsequent outcomes - this is then

accessible to all DGL/Cs.

7.8 Where the BHT Medical Examiners Mortality Screening Form indicates referral for more

detailed retrospective case notes review, the form must include indication of the reasons for

referral. Learning disability deaths, severe mental health (excluding dementia), deaths in

state detention, safe guarding, maternal deaths

http://swanlive/sites/default/files/guideline_408.pdf, stillbirths and deaths due to

cardiopulmonary arrest outside of critical care will be referred to the relevant specialists as

outlined in the Medical Examiners Screening Form. All paediatric deaths will be referred to

the CDOP lead. All learning disability deaths will be referred to the LeDer Lead for a

specialist LeDer review of the death in accordance with regional guidance. A list of contacts

for referral for the above speciality deaths will be available in the Bereavement Office. This

is to ensure multi-agency and regional review as per national guidance. These deaths

should also be subject to M & M review within their respective speciality to inform

departmental learning. NHS improvement recommends the use of the RCP SJR

methodology which is only validated for adults.

Excellent reporting is also encouraged and should be subject to RCP SJR review within the

speciality M & M to ensure replication of excellent practice and rapid audit feedback to

clinical teams.

7.9 The speciality M & M is responsible for conducting RCP SJR review of the RCCR in

accordance with the RCP guidance - see appendix 4 for M & M process. The M & M

Administrator will email the SDU Mortality lead and DGL/C and attach the ME screening

form for collateral information. The Medical Examiner will allocate the consultant at the time

of independent screen to decide the speciality this may not be the same as the consultant

at the time of discharge/death dependent upon the circumstances. For RCP SJR review - an

example is given in appendix 5 with a link to supportive guidance in appendix 6.

8.0 GENERAL NOTES ABOUT WORKING PRACTICES

8.1 The ME on the rota for the day will be expected to be available, physically in the

bereavement office at SMH for one p.a. each afternoon Mon-Friday. In practice there are

almost always a few cases not completed at the end of the day, for a variety of reasons.


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The next day's ME can get started on sorting these out first, and be available to doctors

needing advice.

8.2 The certifying doctor will be expected to speak to an ME before completing the MCCD in

every case. The only exception would be if there is no ME available, or in the case of

urgent certification according to http://swanlive/sites/default/files/guideline_218.pdf Deaths:

Completion of Death Certificates, Role of Coroner, post mortems.

8.3 If the ME gets an increase in cases and as a result there are more than usual left for the

next day, he/she must warn the ME who is on the rota the next day. The ME should allow

for a maximum of 30 minutes per case to include all facets of the ME role including

engagement with bereaved families/carers.

8.4 In these cases the certifying doctor should be warned that another ME will have to contact

him/her next day to complete the cremation forms and that the doctor must be available.

8.5 The notes should be left in the ME office with a clear indication of what has and has not

been done.

8.6 Paediatric cremation forms

8.6.1 MEs will complete the part 2 of paediatric cremation forms upon request apart from

those cases referred to the coroner. In all cases the ME must not attempt to contact

the NoK.

8.6.2 The ME will need to contact the ward to satisfy the legal requirements.

8.6.3 MEs are not involved with paediatric burials.

8.6.4 All paediatric deaths should be referred to the CDOP lead as per instructions on the

BHT Medical Examiners’ Screening Form.

8.7 Fees for part 2 cremation forms

8.7.1 Bereavement Services staff will instruct funeral directors to make cheques payable to

BHT for the part 2 forms completed by an ME.

8.7.2 The fee will be at the standard rate set nationally.

8.7.3 The cheques will be paid in at the cashier's office by the Bereavement Officer to the

allocated BHT cost code

8.7.4 The fees will be used to part- fund the Medical Examiners service.

8.7.5 Cremation fees are not paid in regard to hospital arranged funerals.

8.7.6 For BHT deaths outside of SMH it may not be possible to conform to all requirements

for the crem part 2 forms because the ME is not always physically present on site and

therefore cannot view the body of the deceased as per legal requirements. The crem

part 2 forms on these occasions should be completed by an independent consultant

on site. Where necessary subsequent screen of the medical notes and the

conversation with the NoK can take place by the ME at SMH once the medical notes

have been scanned onto Evolve (this should be within 72hrs as per local guidance).

This should not delay MCCD and completion of crem part 2 forms where applicable.

8.8 Bereavement Office Appointment with Bereaved NoK or nominated representative

8.8.1 Following completion of a MCCD the bereavement officer will contact the NoK or

nominated representative to attend an appointment at the bereavement office.

8.8.2 These appointments can be flexible accordingly to need but are scheduled on the hour

every hour from 1000-1600 Mon to Friday


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8.8.3 On arrival the bereavement officer will confirm, identify and meet to discuss with the

bereaved family/carer the following:

Death Certification and how to register the death - the ME should have already

explained cause of death and need for coroners referral where applicable

Provide any advice regarding funeral arrangements

Provide the death release form and explain that this needs to be given to the

undertaker to be able to release the body of the deceased

Explain the one- off website for notification of multiple agencies regarding the

deceased

Refer to Chaplaincy if immediate bereavement support is required and refer to

bereavement support and learning services if long term support is required with their

consent

Return any property of the deceased with a signed property disclaimer form and

answer any additional queries as able - if further advice is required the ME can be

approached to support.

9. LEAD MEDICAL EXAMINER

9.1 The Lead ME will be responsible for the selection and recruitment of all MEs.

9.2 The Lead ME will be responsible for the training and education of MEs including yearly

updates supported by the Lead Nurse.

9.2 The Lead ME will manage the ME service and be responsible for the day to day running of

the service with support from bereavement services.

9.3 The Lead ME will be responsible for ensuring and monitoring ME performance in

accordance with the ME job description, personal specification and this policy.

9.4 The Lead ME will ensure a robust process of mortality review in accordance with this policy

to include learning from deaths across BHT and externally across organisations with support

from the Lead Nurse.

9.5 The Lead ME will be the AHSN clinical lead and a core member of the CCG countywide

regional mortality group.

10.0 LEAD NURSE FOR QUALITY IMPROVEMENT (learning from deaths)

10.1 A lead nurse for quality improvement will focus on learning from deaths and assist in

collating themes and learning to take actions forward. Learning will feed into existing BHT

work streams, corporate objectives and the granular plan to inform future quality

improvements. The lead nurse will co-ordinate with SDUs and Divisions and be a core

member of the SE panel, AHSN collaborative and CCG countywide regional mortality

group.

10.2 The lead nurse will ensure current mortality review processes remain aligned with national

requirements and monitor compliance accordingly in conjunction with the Lead ME.

10.3 The lead nurse will support the role of ME and lead the transition of change to a new

process of mortality review for BHT, supported by the Lead ME and executive lead.

10.4 The lead nurse will maintain clinical expertise to inform mortality reviews and align to best

practice standards. Learning should be disseminated to front line staff to embed and

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empower change methodology in practice. The lead nurse will also assist the Lead ME

and speciality M & M where required in RCP SJR RCCR.

The Lead nurse will be involved in training and education to include trust induction, and

dissemination of learning from deaths and subsequent quality improvements.

10.5 The lead nurse will support a regional approach to learning from deaths and network with

neighbouring trusts accordingly. The lead nurse will promote divisional and trust wide

learning to front line staff to include links with local universities. The lead nurse will liaise

with senior nurses to support quality improvement in their respective departments.

10.6 The lead nurse will work across organisational and service boundaries to improve care

pathways related to learning from deaths for patients, service users, and families.

10.7 The lead nurse will work with Directorate leads to ensure that learning from death projects

are aligned to organizational priorities.

10.8 The lead nurse will work to embed quality improvements from learning from deaths across

the whole organization working in conjunction with the service improvement team.

10.9 The Lead Nurse with support from the Lead ME will collate an annual report on learning

from deaths for presentation at the trust board quality committee.

11.0 CONSULTATION PROCESS USED TO INFORM THIS POLICY

The details of this policy were discussed through the learning from deaths task and finish group.

Representation was across all divisions and across a broad spectrum of BHT staff. The group

was chaired by the Project Lead for Mortality Review and comprised of consultants, M & M

speciality leads, SDU clinical governance leads, representatives from bereavement services,

senior nurses, palliative care, chaplaincy, clinical governance co-ordinators, service

improvement, the academic health science network and patient experience representatives.

Representatives for the speciality deaths of learning disability, mental health, safe guarding,

state detention and paediatrics were also invited.

Presentations have been given by the Project Lead for Mortality Review to the hospital

management and audit committee, divisional chairs and SDU meetings to ensure engagement

and meaningful consultation.

A draft of the policy was then circulated to a diverse group inviting comments back:

BHT Executive and Non-Executive Lead for the Learning from Deaths Quality Standard

Medical Director

Associate Medical Director

Chief Nurse

All Consultants

Divisional Head Nurses

Bereavement Services

Palliative Care

Head of Services (Pathology)

Morticians

Chaplains

Patient Safety Manager

Coroner

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Registrar

Divisional Governance Leads/Co-ordinators

Staff Associate Specialist Doctors

All members of the learning from deaths Task and Finish Group

12.0 PROPOSED POLICY DISSEMINATION

Launch Oct 2017

Primarily via the Trust Intranet and public website with Trust wide email

Include in policy update

Human Resources to be asked to include reference in staff induction programme

Through training with new doctors - liaise with Medical Director

Cascade to all nursing staff via Director of Nursing

The Internet- publically available

13.0 PROCESS FOR MONITORING COMPLIANCE

The monitoring processes will be continuous to ensure that staff and management are aware of

the Trust expectations in maintaining and improving the BHT Adult Mortality Review Process.

13.1 For staff new to the Trust

Doctors

Attend new starter induction session.

Read the policy within three months of starting (available on the intranet).

Nurses

Read the policy within three months of starting (available on the intranet)

Chaplains

Attend specialist induction session.

Read the policy within one month of starting (available on the intranet).

Bereavement Officers



Shadow an experienced Bereavement Officer, to reflect the Bereavement Officers’

responsibilities as outlined in the policy

Mortuary staff



Shadow an experienced mortuary technician to reflect the mortuary staff responsibilities

as outlined in the policy

For existing staff

All staff currently working in the Trust will be required to read the new policy within three

months of it being published (available on the intranet).

Management monitoring responsibilities

It is the responsibility of the Management to:

o Release staff to attend induction/training sessions, debriefing sessions and

shadowing with other staff.

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o Ensure staff have access to the guideline.

o Keep a record of staff attendance at training sessions and of staff having read the

policy.

o Incorporate discussion regarding the policy within the IPR process.

Other monitoring processes

Discuss issues at departmental team meetings.

Include issues related to the policy as an agenda item for MRG.

14.0 Review and Audit

14.1 The Lead ME will regularly monitor the Medical Examiner Service and report to the

Medical Director monthly in the first instance and then three monthly thereafter. This

work will be supported by the Lead Nurse.

14.2. Learning from Deaths is a standing item at the monthly mortality reduction group

14.3 Learning from deaths should be shared at departmental meetings through existing

clinical governance structures to include academic half days, SDU meetings, SE group

and divisional board. The Lead Nurse will work with teams to develop robust action

plans.

14.4 The SDU Mortality lead is responsible for ensuring action plans are completed in

accordance with agreed time frames supported by the lead nurse for quality

improvement.

14.5 The Lead Nurse in conjunction with the SDU Mortality lead is also responsible for

disseminating learning to front line staff and where applicable to HMAC and lessons

learnt to promote trust wide learning.

14.6 The DGC/L will utilise an action plan tracker to monitor compliance with actions from M

& M SJR RCRR and SE panel.

14.7 Report performance on quality template and to Trust Board via Quality Committee.

14.8 Learning from deaths should be a standing item at Divisional Performance Meetings.

15.0 EQUALITY IMPACT ASSESSMENT

15.1 BHT recognises the diversity of the local community it serves. Our aim therefore is to

provide a safe environment free from discrimination and treat all individuals fairly with

dignity and appropriately according to their needs.

15.2 As part of its development, this policy and its impact on equality have been reviewed and

no detriment was identified.

15.3 Those members of the community who request urgent certification and release are

catered for by the local agreement with the coroner see


16.0 REFERENCES

1 National Guidance on Learning from Deaths; a Framework for NHS Trusts and NHS

Foundation Trusts on Identifying, Reporting, Investigating and Learning from Deaths in

Care - First edition March 2017


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2 Learning, Candour and Accountability; a review of the way NHS trusts review and

investigate the deaths of patients in England. December 2016

³ DOH Reforming death certification introducing scrutiny by medical examiners Lessons

from the pilots of the reforms set out in the Coroners and Justice Act 2009

4 https://www.rcpath.org/discover-pathology/news/medical-examiner-delay.html

5 http://www.endoflifecareforadults.nhs.uk/ The National End of Life Care Strategy

and annual progress reports (2008)

17.0 ACKNOWLEDGEMENTS

Grateful thanks are extended to Professor Peter Furness, Lead Medical Examiner for England

at University Hospitals Leicester for his expertise and invaluable advice to enable introduction of

the medical examiner role at BHT.

Thanks are also extended to Kathleen Griffiths, Senior Bereavement Manager at Gloucester

and Cheltenham NHS Trust for her invaluable advice and support in taking this initiative

forward.

Thanks also go to Rebecca Broughton, Head of clinical outcomes and effectiveness at

University Hospitals Leicester for sharing and advising on outcomes from learning from deaths.

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APPENDIX 1 MEDICAL EXAMINER JOB DESCRIPTION AND PERSON SPECIFICATION

JOB DESCRIPTION JOB TITLE: BHT Medical Examiner GRADE: Consultant (or equivalent) SALARY: Consultant Scale

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.

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KEY WORKING RELATIONSHIPS

Lead Medical Examiner

Lead Nurse for Quality Improvement

Consultant Body

Corporate Nursing team

Bereavement Services

Hospital Chaplaincy

Mortuary Services

Specialty M&M Clinical Governance Leads

Divisional Clinical Governance Leads/Co-ordinators

Pathologists

Coroner and Coroners Officers

Registrar

Divisional Leads

Medical Director

MAIN DUTIES - MEDICAL EXAMINER

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.




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


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

Buckinghamshire Healthcare NHS Trust (BHT) mortality review process.



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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

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