This policy sets out the Northamptonshire Healthcare NHS Foundation Trust's approach to meeting the National Guidance on Learning from Deaths (NQB 2017) and how they seek to learn from the care provided to patients who die. This policy makes clear the procedure for responding to and learning from patient deaths across the Trust including:
How the process will respond to the death of an individual.
Determine the categories and selection of deaths in scope for review.
How the Trust engages with bereaved families and carers, including how the trust supports them and involves them in investigations.
How staff affected by the deaths of patients will be supported by the Trust.
How the Trust learns from deaths to improve and inform clinical practice.
The themes and issues identified from review and investigation, including examples of good practice.
How the findings, themes and issues from reviews and investigations will be used to inform and support quality improvement activity; any other actions taken, and progress in implementation.
How the Trust collects specific information every quarter of those who die, outcomes of reviews of care and publish this information on a quarterly basis to public board meetings.
This policy covers how Dorset Healthcare (DHC) University NHS Foundation Trust responds to patient deaths in care generally, not just those amounting to 'serious incidents', which will continue to be dealt with under the existing NHS Improvement’s 2015 'Serious Incident Framework'.
Key learning points
What happened, where and when? Give a brief history of the incident.
What is it that made the incident ‘critical’?
What were your immediate thoughts and responses?
What are your thoughts now? What has changed/developed your thinking?
What have you learned about (your) practice from this?
How might your practice change and develop as a result of this analysis and learning?