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56 Learning from deaths: the structured judgment review
  1. Stephanie Lister-Flynn1 and
  2. Emily Sills2
  1. 1St Catherine’s Hospice, Crawley
  2. 2Princess Alice Hospice, Esher


Background Most acute trusts have systems in place to review hospital deaths to identify areas that could be improved and areas of good practice. Following on from the National Mortality Case Record Review, the Learning From Deaths Guidance published in 2017 sets key requirements to ensure organisations effectively respond to and learn from deaths. This includes introduction of structured case record reviews when reviewing deaths. Following this guidance, we set up a monthly educational programme at Woking and Sam Beare Hospice from November 2019-September 2020, including monthly adapted ‘Structured Judgment Reviews’ (SJR) of nominated deaths.

Methods Each month a patient death was selected from a list that teams felt further discussion would be beneficial. An ‘independent reviewer’, not directly involved in the care, would objectively review the notes. The phases of care focused on were:

  • First assessment

  • Ongoing care

  • Communication with relatives/professionals

  • Advance Care Planning

  • End–of–life care

  • Overall assessment

Each domain was ranked from 1 (poor care) to 5 (excellent care), and key learning points discussed at a monthly meeting open to all clinical staff, and learning points later circulated. Questionnaires were given to staff at the final presentation.

Results Six reviews in total were possible (due to Covid-19 these were not possible every month). Questionnaire responses were overwhelming positive with 100% stating that it was useful to be able to review deaths in this format, written comments gained were positive (on poster). The monthly programme has now been taken on regularly at the hospice as a learning event.

Conclusions This has been a positive learning experience, for both individuals and at an organisational level. SJRs received overwhelmingly positive responses from staff and allow informal discussions which also help to ensure organisations effectively respond to and learn from deaths. This could be easily replicated at other hospices to support learning.

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