In the NHS structured judgement case note reviews have been used to assess the quality of a variety of hospital based care processes and are now widely used for mortality reviews (Royal College of Physicians, National Mortality Case Record Review Programme).

At Trinity, we wanted to use information from our mortality data across different areas of the hospice to maximise any learning and potential improvement for patients and their loved ones. As a starting point we decided to consider all patients who had been referred to our community services but who had died before being seen. Our approach involves monthly meetings of the same team members who consider each case in detail using a structured approach.

Specific stages of the referral process are reviewed including:

• Referral form (including urgency).

• Communication with referrer.

• Communication with patient +/- family +/- care home staff.

• Triage.

• First contact (including time to contact).

• Communication around death.

For each phase a score is given from 1-5 as below (if the phase is not applicable to the case it is given the score 0).

1. Very poor.

2. Poor.

3. Adequate.

4. Good.

5. Excellent.

Comments are also logged for each case if it is felt that anything could have been done differently.

From the analysis of individual cases we have already found several areas where small changes in practice have led to improvements for patients and their families including:

• Bereavement calls to the loved ones of all those referred not only those who have been seen.

• Changes to how we support nursing homes to ensure immediate support is provided for patients.

• More efficient processes for different members of the workforce.

• Not delaying patient contact whilst waiting for additional clinical information from referrers.

It is hoped that we will be able to continue this work in other areas of the hospice.