Background Morbidity and mortality (M&M) meetings are a recognised tool for improving quality of care. We have developed an M&M process within the HSPCT at University Hospitals of Leicester (UHL). Before this the HSPCT contributed to other specialty M&Ms but did not independently review team involvement in cases using Structured Judgement Review (SJR) methodology.

Aim The aim was to develop our own practice within the team, and to identify areas to improve end of life care across the Trust, by providing feedback into the local Learning from Deaths framework at Trust level.

Methods A quarterly meeting was established with Palliative Medicine Consultant and CNS leads. Referrals were to an electronic mailbox and the leads jointly completed the Structured Judgement Reviews using the Trust template. Cases were presented by the leads who facilitated discussion, concluding with agreed judgements and actions. The finalised SJRs were used as minutes.

Results Over the first three meetings 10 patients were discussed. Referrals increased with 2, 3 and 5 cases discussed in the first, second and third meeting respectively. Referrals were from a variety of sources: 2 from Medical Examiners, 5 by other speciality M&M leads or consultants and 3 from HSPCT consultants or CNSs. Learning identified was varied and has been grouped into themes: improving outward communication from the HSPCT to specialty teams, areas for changes to current Trust guidelines/policies, areas for education and development.

Conclusions The M&M has provided a formal way to report back, with case-based evidence, at Trust level and allowed greater communication with other specialities. Doctors and specialist nurses value the time to reflect on clinical aspects of their work. Prioritising protected time for the meeting and enabling clear plans to improve care were key. The meeting has become an established part of the team culture.