1. 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

2. 306

3. Thematic Analysis of Weekly Audits of Inpatient Deaths

4. Thematic Analysis of Weekly Audits of Inpatient Deaths

5. 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

6. 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

7. THANK YOU