Background Over recent decades multiple health care inquiries including Shipman; Mazars; Francis; and Gosport have identified failings in care (Norris & Shepheard, 2017) providing important recommendations to help create a health and care system that can identify failings in patient care before irreversible harm or avoidable deaths occur. Additional research has suggested that quality gaps can also be identified though mortality review (Kobewka, van Walraven, Turnbull, et al., 2017). In June 2019 our commissioners asked our hospice to perform mortality reviews on 5% of our deaths.

Aims The quality leads wanted to create a hospice specific learning from deaths (LFD) tool to support both random review and specific deeper dives into hospice deaths.

To take a wider learning and development approach to improve quality of our care and patient experience in a robust and time efficient way.

Methods We examined mortality review models including the National Mortality Case Record Review Programme’s Structure judgment review and the Gold Standards Framework significant event analysis to create our inpatient hospice specific LFD tool. This tool helps identify near miss events and recognise areas of improvement that do not reach the threshold for triggering our incident reporting process. The review group, led by our Care Quality Lead, includes senior nursing and medical input and an external medical reviewer.

Results Two patients are reviewed monthly, identified randomly by an administrator; by multidisciplinary team request, following a sudden or unexpected death; or as a result of patient and family feedback. An action tracker is reviewed monthly and an annual review identifies themes or wider actions.

Outcome This process has become a key trigger for quality improvement in the hospice. It also prompted identification of a direct pathway to request hospital mortality review. It has enhanced our open culture for learning and augmented service development to improve the quality of care and patient and family experience.