Summary
This report examines the reporting of patient deaths at the Norfolk and Suffolk Foundation NHS Trust (NSFT) between April 2019 and October 2022. It was undertaken by Grant Thornton on behalf of the NHS Suffolk and North East Essex and NHS Norfolk and Waveney integrated care boards at NSFT’s request.
Content
Some of the key patient safety findings detailed in this report include:
- Between April 2019 and October 2022 the Trust recorded over 8,000 unexpected deaths.
- For 1,953 patients whose death is consider part of the Trust’s mortality reporting, the date of death is within one month of discharge. This incudes 278 patients whose date of discharge is the same day as the day they died. The report suggests that given the number of patients who die within a month of discharge, more work is needed to understand this cohort, ensure this data is accurate and act on any learning.
- Between April 2019 and September 2022, 1868 deaths had an ethnicity recorded as ‘not stated’ and 1009 as ‘not known’. The report notes that without knowing ethnicities represented within the ‘not stated’ and ‘not known’ categories, the Trust will struggle to accurately understand whether or not there is a disproportionate mortality impact on certain protected characteristics.
- NSFT’s approach to reporting mortality data, both internally and externally, has been inconsistent, in particular the process of categorising and grouping expected and unexpected deaths.
- Reporting on mortality data to the Board has been inconsistent, with the report citing that in over eight consecutive board reports, information and the methods of presentation changed six times.
- The Trust’s process for determining the categorisation of death as expected or unexpected is not clear or auditable.
- While the report states NSFT’s governance structures around mortality recording are in line with national guidance, it found the operational understanding of this to be unclear. One area of concern that it highlights is a confused picture around the senior ownership of this.
The report makes 16 recommendations across four key themes for NSFT which include:
- Improve the mortality data pathway to automate and digitise the production of mortality reporting.
- Agree a standardised reporting structure for internal and external reporting, and provide the tools to interrogate the data.
- Improve the controls over mortality reporting and ensure clinical oversight, validation and use of the information reported.
- Establish a clear improvement plan to address the issues identified in this report.
Grant Thornton: Norfolk and Suffolk Foundation Trust’s mortality recording and reporting (23 May 2023)
https://suffolkandnortheastessex.icb.nhs.uk/wp-content/uploads/2023/06/NSFT-Mortality-data-recording-June-2023-FINAL.pdf
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