Reviewing the Care of Patients Who Have Died

At the Shrewsbury and Telford Hospital NHS Trust we are constantly trying to improve the care we provide. One of the ways in which we do this is by examining the care we have provided to our patients at the end of their life.

Internal Review

As the family or carer of the patient, your views are important to us, and the Bereavement survey is one way we would ask you to provide feedback.

All patients who die in the Shrewsbury and Telford Hospitals will have their care reviewed, through examination of the patient’s case records, by one or more Consultants who were not directly involved in the patient’s care. The anonymous results of these reviews are discussed as a whole, at a number of meetings, from Specialty Governance to the Trust Board.

For the vast majority of patients, care is usually assessed as adequate or better, and the deaths are not considered preventable.  Improvements will be made to care processes and pathways as a result of learning from these reviews.  Feedback is not usually given on an individual patient basis to the families, unless the hospital is aware that they have raised concerns or questions, or the Trust identifies any problems in care which may have affected the patient’s clinical outcome.

External Review

Some patients will also be referred for external investigations:

  1. Referrals to the Coroner – this usually occurs where the cause of death is not known or is considered ‘unnatural’. i.e. an unexpected death, due to an accident, including falls, or possibly following medical intervention (for more information please visit the GOV.UK Website).
  2. Deaths of Patients with Learning Disabilities (for more information please visit the University of Bristol Website).
  3. Deaths of Patients with Serious mental health illnesses
  4. Children (for more information please visit the Lullaby Trust Website).

These investigations are usually more in–depth, and families and carers will be asked for their views, and given feedback on the outcome of the investigation.

The process for the review of Patient Deaths follows national guidance from ‘The Learning from Deaths Framework’. We also have a Shrewsbury and Telford Hospital NHS Trust policy.

When things go wrong

In a small number of cases, concerns may be raised that acts or omissions in care may have contributed to the patient’s death. These may be raised any time after the patient’s death.

If a family member or carer wishes to raise concerns, this should be done, ideally as soon as possible, with the Ward or Consultant in charge of the patient’s care. If they do not feel able to do this, they can approach PALS, the Bereavement Team, or use the formal Complaints Procedure. Any concern raised about the cause of death or end of life care, is treated with the utmost seriousness by the Trust and, independently investigated of the clinical teams involved.

Where it is known, or becomes apparent that an incident has occurred, or the care was sub-optimal to the extent that it might have contributed to a person’s death, the Trust will report the death to the Coroner, and any other external agencies under the Serious Incident Reporting Framework, HSE RIDDOR reporting scheme, or other external mandatory reporting schemes. Further information about this can be found on the NHS Improvement Serious Incident Framework.

In such cases, the Trust has a statutory duty, known as the Duty of Candour, to notify families and carers; keep them informed of the investigation process; invite them to participate in the investigation if they wish, and; to be told the outcome of the investigation.