MEs are a key element of the death certification reforms, which, once in place, will deliver a more comprehensive system of assurances for all non-coronial deaths, regardless of whether the deceased is buried or cremated. MEs will be employed in the NHS system, ensuring lines of accountability are separate from NHS Acute Trusts but allowing for access to information in the sensitive and urgent timescales to register a death.
This case study outlines the approach of South Tees Hospitals NHS Foundation Trust as one of the early adopter sites.
To date, the following learning points have been identified and explored:
End of Life Care, ceilings of care and avoidable admissions
Some investigations have highlighted cases where the End of Life Care pathway could have either been established or fully implemented, where this would have been of benefit to patients and their families. Some patients may not have been cared for in the right location, and some admissions could have been avoided if the End of Life Care pathway had been suitably established and followed.
Early detection and response to physiological deterioration, and effective communication
Response stretched by implementation of National Early Warning Score (NEWS) but still learning around effective communication of escalation. The use of standardised communication tools is essential.
Record keeping and organisation of medical records
Some learning was identified in relation to the accuracy and completeness of medical records. It was evident that not all records are reflective of the clinical picture.
Discussion with specialty teams is vital to support the investigation
An independent review by the ME should be further supported by speciality ‘experts’, and if possible, peer review from other trusts can be sought to allow for full independent review. Seeking speciality opinion from those not directly involved with the case within STHFT has also been shown to be effective.
Pathways for links to wider clinical governance processes have been strengthened.
The resources include peer-reviewed content on identifying and managing sepsis in the community, in older people and in children from Emergency Nurse, Nursing Children and Young People, Nursing Older People and Primary Health Care.
In this report the CQC have seen much good and outstanding care, in particular around:
staff interactions with patients
leadership and engagement with staff and patients.
However, there were a number of areas where services needed to make substantial improvements:
Between April and June 2018, the RCPCH Children and Young People’s Engagement Team met with over 130 children, young people and families to collect their views on ‘service contact ability’ and family mental health. Over 2335 questionnaires were submitted by children, young people and their carers.
This submission demonstrates:
impact from patient and public involvement
embedded involvement to sustain QI