1. Operational Process for Mortality
Exclusions
Non elective death on ITU/CICU
Out of Hospital Cardiac Arrest
Operational Process for Mortality
Template
Exclusions
Non elective death on ITU/CICU
Out of Hospital Cardiac Arrest
Exclusions
Non elective death on ITU/CICU
Out of Hospital Cardiac Arrest
Exclusions
Non elective death on ITU/CICU
Out of Hospital Cardiac Arrest
Exclusions
Non elective death on ITU/CICU
Out of Hospital Cardiac Arrest
Exclusions
Non elective death on ITU/CICU
Out of Hospital Cardiac Arrest

2. Operational Process for Mortality
University Hospitals Bristol NHS Foundation Trust
Exclusions
Out of Hospital Cardiac Arrest
Division
Themes and scores collated at Divisional level
Dashboard populated
Feedback to Divisional Board
Inclusion in specialty M+M
In some cases feedback to family
Structured judgement review
Including avoidability of death score
Automatic inclusion for Structured Judgement Review
Elective care
If issues with ward care for ITU/CICU deaths subject to an ICNARC review
Patients with learning difficulties
Patients with DOLs in last episode of care
16-18 year olds
Family concerns
Alerts from risk management group
Patients who are subject of a serious incident investigation in their last episode of care
If overall care scored at 1 or 2 then second review undertaken by MD office and consideration for clinical incident/ serious incident reporting including Duty of Candour obligation
If death rated greater than 50:50 avoidable
Mortality Surveillance Group
Additional information from ITU/CICU, Paediatrics/ O+G
Dashboard review
Cross Trust themes identified and fed to QI Academy
Good practice and/or poor care fed back to teams from MD office
Screening process
Remainder of notes screened using standardised tool and if any clinical issues identified then proceed to structured judgement review.
Reports
Quality and Outcomes Committee
Coal Face teams – quarterly Mortality bulletin

3. General specialities inclusion criteria for SJR
All deaths which do not meet exclusion criteria below
Operational Process for Mortality
North Bristol NHS Trust
Division
Themes and scores collated at Divisional level – also to include Quality and Safety thematic elements (Quality Synopsis)
National Dashboard populated
Specialty Dashboard
Feedback to Divisional Leads
Inclusion in specialty M+M
In some cases feedback to family
General specialities exclusion criteria for SJR
Cases already in the Serious Incident Process where an RCA is being written at the time of uploading notes
Cases already in the Legal process where an Inquest has been opened and/or a Coroner’s investigation is ongoing
Structured judgement review e-tool
Performed on all cases (or a sample of patients in Medicine for Older People, Respiratory, Stroke, Acute Medicine specialties)
Including assessment of ‘more likely than not to have resulted from problems in healthcare’
SCREENING PROCESS prior to SCR in Medicine for Older People, Respiratory, Stroke, Acute Medicine specialties
Notes of all deaths screened using standardised e-tool with automatic inclusion criteria.
Screening to be completed by junior doctor who contacts responsible consultant at time of death certification.
If criteria met then case proceeds to SCR.
SJR will also be performed on a random sample of those cases screened out
If care scored at 1 or 2 (Very Poor or Poor) in overall phase of care then a clinical incident must be raised and Duty of Candour process followed
If a Care Delivery Problem has been identified which most likely contributed to death, a clinical incident must be raised and the Patient Safety Assurance and Audit Service must be contacted to commence the Serious Incident process.
Quality Surveillance Group
Dashboard review
Cross Trust themes identified and fed to Quality and Patient Safety Programme
Good Practice fed back to teams
Automatic inclusion for SCR in Medicine for Older People, Respiratory, Stroke, Acute Medicine specialties
Elective care
Patients with learning difficulties
Patients under Mental Health Section
Family or staff concerns
Alerts from risk management group
A death where there may be important lessons to be learned for the team or department (these lessons may be areas of excellence as well as areas
Reports
Board Report
Quality Committee Report
Clinical teams receive thematic communication

4. Operational Process for Mortality
Great Western Hospitals NHS Foundation Trust
Mortuary
Patient transferred to mortuary; notes and paperwork left with mortuary staff to process
Doctor completes death certificate paperwork (within 3 working days).
Mortuary staff update cause of death and doctor’s name on EDS
Clinical coding review notes to complete coding of inpatient spell
Health records
Deceased Clerk retrieves notes from Mortuary throughout the day
Collections AM: prepared for scanning for PM
Collections PM: prepared for scanning next AM
Scanned Episode saved as individual entry on Medway for ease of identification
Ward (patient dies)
Dr completes diagnosis of death (section 1) on the ward
Nurse present at death completes notification of death and mortuary checklist
Ward clerk updates ‘Status’ and details onto Medway
Automatic inclusion for Structured Judgement Review
Cardiac Arrests - Identified by QI Team
Elective Surgery – Identified by Information Team
Learning disabilities – Identified by LD Lead
CQC/Dr Foster Alerts – Identified by Clinical Audit
Family Concerns – Identified by PALS
Serious Incidents – Identified by Clinical Risk
Other reviews identified locally by Specialities
Speciality level review(s)
Specialities/M&M Lead identify cases for SJR prior to M&M
Cases notes shared amongst team (local arrangement)
Case note review and scores recorded on Mortality Database
Non-mandatory patients – identify cases for learning to put forward for discussion at next M&M
Mandatory categories – ALL discussed M&M
Exclusions apply
Information
Daily mortality list sent to all wards by informatics (automated)
Ward clerks ‘validate’ information (consultant/speciality)
Corrections sent to the PAS team to action on Medway
Deceased patient level data uploaded to National Mortality Database on weekly basis
Notification sent to M&M Leads and Leads from Central teams
Speciality M&M lead
Provide senior leadership and support with Speciality M&M Meetings as outlined in ToR: Core membership; frequency of meetings; roles and responsibilities; reporting
Member of Trust Mortality Group (by Default)
To report on Mortality performance/learning to the Trust Mortality Group
Ensure Speciality Dashboard/reports are disseminated to all members of the team and channelled through local governance process where required
Clinical audit
Receive speciality attendance sheets
Populate speciality dashboards and return to M&M Lead
Prepare Trustwide Dashboard: monthly
Prepare Trustwide report: quarterly
Exclusions
Paediatrics
Perinatal
Please refer to the Terms of Reference for Perinatal and Paediatric Mortality and Morbidity which can be found on the GWH intranet site.
Patient Quality Committee
Trust Mortality Group
Meet 3rd Wednesday of Mont
Review Monthly Trustwide dashboard-
Rates of reviews undertaken
Outcomes/learning from reviews
Identify/action 2nd level reviews
Review Speciality dashboards-
Review Quarterly Report
Provide Dashboard/Report-
Dr Foster Reviews/Alerts
Identification/Outcomes from ‘other’ locally identified Mortality Reviews (i.e. Christmas Mortality).
Executive Committee
Clinical Commissioning Group