Learning from deaths is essential

The tragic death of teenager Connor Sparrowhawk, who has autism, sent shockwaves through mental health services and prompted the government to demand better processes to learn from deaths. The NHS has a number of processes in place to investigate what has happened in such circumstances, including serious incidents investigations.

The death of a loved one is a very difficult time for family and carers and they should be offered support to help them cope, including any legal processes that need to be gone through.

But what about cases when an investigation is not triggered or when a patient’s care was considered to have been good? Surely there is still much that can be learned and shared from these cases? To ensure that organisations provide the best care possible, it is vital that they continuously learn from all patients that they care for, not just those where issues are identified that trigger investigations.

The UK is ahead of other countries in their ability to learn from any deaths of patients, including those that are expected deaths.

Care review tool

Today the Royal College of Psychiatrists launches a care review tool and guidance that will support mortality reviews within mental health organisations. This guidance provides trusts with a method to conduct case note reviews into deaths where no issues that trigger existing processes are identified.

The work on learning from deaths aims to support the learning process and helps to ensure that organisations have processes in place to identify both the things that they can improve and the areas where they perform well, to help them to continually improve patient care

There are some groups of patients whose care will automatically be reviewed due to a diagnosis of psychosis or eating disorder, or where they were under the crisis teams or were an inpatient in a mental health unit. In addition, where family, carers, or staff have raised concerns, a review will be triggered.

Whilst these “red flags” trigger a review of patients’ care, the guidance encourages organisations to examine the notes of a random selection of other patients who received care from the organisation.

The work on learning from deaths aims to support the learning process and helps to ensure that organisations have processes in place to identify both the things that they can improve and the areas where they perform well, to help them to continually improve patient care.

There are concerns in the NHS about a “blame culture” but, by looking at situations where positive practice is recognised, it will inspire a change in culture, helping clinicians to feel comfortable in being upfront and open about the quality of care being provided. It will enable them to point out where practices can be improved as well as identifying positives and will hopefully also improve staff morale.

The guidance produced by the Royal College of Psychiatrists will help mental health organisations identify common themes where further improvement is required in patient care.

Areas for improvement

Indeed, several trusts who have piloted the tool have identified a number of areas for improvement, for example improvements in the waiting time for assessment, better reviews of patients with dementia who are prescribed antipsychotics, discussions around end of life care planning, and improved communication with family.

Even in the pilot stages of the learning from deaths work, it is encouraging to see that trusts have been able to implement change to improve patient care.

As an example, one family told me that staff attending the funeral of their loved one meant a lot to them. In another example, a family reported that the prompt response, information provided, and support offered was appreciated when the patient was approaching the end of their life.

The death of a loved one is a very difficult time for family and carers, and they should be welcome to contribute to the review process to facilitate learning and improvement within organisations. If family or carers have raised concerns, the review process will ensure that they receive feedback to answer their questions and, where appropriate, a more indepth investigation will be triggered.

When the patient and family has had a positive experience of care, it is still important that opportunities to provide feedback are offered. Identifying areas of good practice can help to ensure such care is continued and shared with other teams to support further learning.

As an example, one family told me that staff attending the funeral of their loved one meant a lot to them. In another example, a family reported that the prompt response, information provided, and support offered was appreciated when the patient was approaching the end of their life. Sharing such examples not only with the staff involved, but with the wider organisation, has clear benefits and can enhance the practice across all teams.

Patients often receive care from several different organisations; being able to join up the processes within each organisation is absolutely vital, as issues often arise in the pathways between organisations. As a liaison psychiatrist, I am always acutely aware of the importance of true integration in patient care, and I would like to ensure that we have this same integration within our learning when someone dies.

The adoption of the care review tool by individual organisations is the first step in the journey of learning from deaths.