National Learning Session - 10th June 2011 Improving Care, Delivering Quality Hywel Dda Health Board Dr Simon Mahon – Medical Director Insert name of presentation on Master Slide

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Thematic Analysis of Weekly Audits of Inpatient Deaths

Thematic Analysis of Weekly Audits of Inpatient Deaths

Themes identified There was spread of issues across the 3 counties, although the most common were: County 1 - lack of following guidelines / protocols County 2 - Documentation County 3 - Team factors such as teamwork / communication / supervision

General observations Specific interests of reviewers could bias the types of concern highlighted There is evidence of education of the auditors Comments from consultants welcoming the opportunity to reflect on their practice and improve systems

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