Background The NHS National Quality Board published its first edition of ‘National Guidance on Learning from Deaths’ in March 2017. Although a charitable hospice care provider, Phyllis Tuckwell Hospice Care (PTHC) followed NHS, Care Quality Commission (2016, 2018) and Royal College of Physicians (2016) guidance and established a pilot process for learning from deaths in 2018.
Aims This report outlines the approach taken to establish a new process and culture of learning from deaths in a UK hospice and shares our experience as a model of good practice.
Methods Terms of Reference (TOR) were established to guide the structure and the culture of the learning from deaths process. The TOR linked learning from deaths with PTHC’s core values including keeping patient care at the heart of our practice, acting with honesty and integrity and fostering a culture of continuous learning.
Results The first Learning from Deaths review occurred in December 2018 following the death of a patient during transfer to hospital for acute treatment. An outcome of this meeting was to review the care of three further patients who were transferred to the acute sector. Learning translated directly into a change in clinical practice in August 2019 through the roll-out of the National Early Warning Score 2 (Royal College of Physicians, 2017; Frinton, Malia, Owen, et al., 2019) on the inpatient unit. The learning from deaths approach is now integrated into PTHC’s clinical governance system and 19 cases have been reviewed between April 2019 and March 2021.
Conclusions Conducting formal reviews into the deaths of patients under hospice care offers an important opportunity for reflection and learning to improve services for future patients. Senior support and a constructive, positive culture are essential facilitators in establishing staff engagement with the process. A literature review did not identify any reports of existing models for learning from deaths in hospice care. This innovative approach is transferrable to other charitable units.
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