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117 Are we learning from deaths? Evaluating a new acute hospital Frailty, Stroke Medicine and Supportive & Palliative Care (SPCT) Teams Mortality Meeting
  1. Hilary Williams,
  2. Farida Malik and
  3. Rannie Nahas
  1. East Sussex Healthcare Trust


Background A new monthly mortality meeting (MM) between SPCT/Frailty/Stroke Medicine teams was launched to review & learn from selected hospital deaths. Learning from deaths is a key aspect of medical education, registration, ethical obligation and contributes to meaning derived from our roles. However, few organisations use a validated approach despite availability of toolkits. The aim was to evaluate the effectiveness & utility of the MM.

Methods MM attendees were invited by email to complete an anonymised, semi-structured cross-sectional online survey twelve months after MM inception. Questions covered practical aspects surrounding MM access plus understanding of process. Results were fed back to the MM where joint participant discussion informed next steps required.

Results Response rate 32%. Majority of respondents were Consultant (7/20)/CNS (6/20). Positives to MM included access, timing and lessons learnt. 95% (19/20) satisfied with monthly frequency, 85% comfortable with meeting timing. SJR process was either ‘understood’/’partly understood’ by 75%. MDT nature of learning widely valued. 85% reported meeting had positively impacted their reflective learning. However, 65% unaware of case selection criteria, 40% unfamiliar with SJR process/wanted to understand more. 35% participants preferred advance notice of cases. Following feedback of results to MM, the selection process was clarified as were plans to develop cross site participation.

Conclusions The meeting was seen as a beneficial intervention. Operational and content aspects have been incorporated to improve future MM effectiveness and utility.

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