Trust performance & learning from deaths

2019/20

Indicator

 

Q1

 

Q2

 

Q3

 

Q4

 

Year End

Learning Points

 

 

Patient Safety: Total percentage inpatient deaths subject to a case record review

 

100%

 

100.00%

 

 

 

 

 

100%

 

Patient Safety: Total number of in-patient deaths subject to a case record review identifying that there was a  problem in care provided

 

1

 

1

 

 

 

 

 

2

Serious incident reviews have been undertaken. The learning will be provided in the next Learning from Experience report Trimester 2, 2019/20

Patient Safety: Total percentage of  deaths reported by and to the Trust(including inpatient deaths)subject to a case record review

 

100%

 

97%

 

 

 

 

 

99%

 

Patient Safety: Total number of deaths (including inpatient deaths) subject to a case record review estimated due to problems in care

 

0

 

0

 

 

 

 

 

0

In response to the high number of case record reviews resulting in no problems in care, the clinical audit programme will be increased from 5% to audit 10% of reviews from April 2019.  

2018/19

Indicator 

Q1
Apr-Jun
Q2
Jul-Sep
Q3
Oct-Dec
Q4
Jan-Mar
Year End Learning Points
Patient Safety: Total % inpatient deaths subject to a case record review 100.00% 100.00% 100.00% N/A 100% Learning points identified (Requirement from Q3):

Apr-17: Referral pathways implemented for long term conditions  to inform specialist nursing/medical care.
July-17: Improved safer transfer of patient care between CWP and acute trust. 
Patient Safety: Total number of inpatient deaths subject to a case record review identifying that there may have been a problem in the care provided 1 2 0 N/A 3
Patient Safety: Total % deaths reported by and to the Trust (including inpatient deaths) subject to a case record review 15% 17% 18% 20% 18% Learning points identified (Requirement from Q3):

Oct-17: Need to review adequacy of systems to reliably contact the District Nursing Service out of hours.
Nov-17: Improvements required to communication with families in relation to medication regimens in place for people receiving palliative care.
Patient Safety: Total number of deaths (including inpatient deaths) subject to a case record review identifying that there may have been a problem in the care provided 0 2 2 0 4

                                                                                                                                                      

2017/18

You can read the Trust performance 2017/18 report here. 

 

Indicator  Q1
Apr-Jun
Q2
Jul-Sep
Q3
Oct-Dec
Q4
Jan-Mar
Year End Learning Points
Patient Safety: Total % inpatient deaths subject to a case record review 100.00% N/A N/A N/A 100% N/A
Patient Safety: Total number of inpatient deaths subject to a case record review identifying that there may have been a problem in the care provided          
Patient Safety: Total % deaths reported by and to the Trust (including inpatient deaths) subject to a case record review 34% 54%        
Patient Safety: Total number of deaths (including inpatient deaths) subject to a case record review identifying that there may have been a problem in the care provided          

 

You can read the Trust performance 2018/19 report here. 

Click here to see the Learning from Experience report – trimester 3 2017/18

 

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