20718-Learning from Deaths

I am doing a research project regarding 'learning from deaths in a prehospital system'.

Are you able to provide me with any information regarding how you log and review patient deaths? And any of the systems that you have in place which would allow your clinicians to learn from that cohort of patients? If no such system exist, this would be equally important and important for me to know.

  • Reference:
    20718
  • Response:
    I am doing a research project regarding 'learning from deaths in a prehospital system'.

    Are you able to provide me with any information regarding how you log and review patient deaths? And any of the systems that you have in place which would allow your clinicians to learn from that cohort of patients? If no such system exist, this would be equally important and important for me to know.

     

    • The Trust currently uses an incident reporting system to identify any incidents where a patient potentially or actually comes to harm following an act of omission or commission by the service. High numbers of incidents are reported every month and the Trust continues to see a month-on-month increase in incident reporting. The high numbers of incidents reported are associated with a low level of harm, indicating a good safety culture embedded at the organisation.
    • A robust review process is followed and appropriate incidents are managed via the NHSE SI Framework. Every SI report identifies learning and actions are taken to reduce the risk of harm to service users. This includes patients who have died whilst in our care.
    • The Trust is also working with regulatory bodies, other UK ambulance trusts, and NHS funded care providers, to develop its nationally-driven Learning from Deaths Policy and associated methodology. The Trust is currently undertaking a scoping and identification exercise to understanding the size of cohort of patients that this initiative will incorporate. As is stipulated, the policy will be finalised and released by 1 December 2019 and the Trust will aim to meet national requirements to start reporting on data from Q1 2020/21, drawing from data of those deaths identified in Q4 2019/20.
    • In terms of embedding the lessons learnt from incidents, the Trust has recently appointed a Patient Safety Integration Lead. The role is designed to take learning from SIs and from the LfD initiative and make it accessible to all members of staff via the use of varying platforms and media. This adds to the already robust SI action completion process already employed by the Trust and is hoped to demonstrate further reduced harm to services users than what has already been reported in recent years.
  • Area:
    Trust wide
  • Category:
    Clinical
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