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P-123 Mortality review – Learning from deaths in palliative care settings
  1. Ross Chirgwin and
  2. Julia Thompson
  1. St Helena Hospice, Colchester, UK


Background Mortality review is a means of reviewing the quality of care patients receive at or near the time of death (National Quality Board. National guidance on learning from deaths: A framework for NHS Trust on identifying, reporting, investigating, and learning from deaths in care. 2017). This is advocated across all healthcare settings and the results can highlight deficits in service provision, knowledge, and skills (Care Quality Commission. Learning from deaths – A review of the first year of NHS trusts implementing the national guidance. 2019). This learning can then be used to inform service delivery and educational needs.

Aims To review the deaths of patients dying within their own home, hospice, hospital, and care home setting. Highlighting exemplary or poor experiences and exploring factors which contributed towards patients dying contrary to a patient’s preferred place of death (PPD).

Method Each month a multidisciplinary team met to review patients chosen at random by a non-clinical team member. Patients’ records were reviewed using an audit tool devised by the team evaluating areas including recognising dying, communication, symptom control, advance care planning (ACP), and PPD.


  • Between April 2022 and March 2023 a total of 40 patients were reviewed.

  • 90% of patients discussed had ACP discussions documented.

  • 72.5% of patients had achieved their PPD.

  • For the majority of patients, there was excellent documentation regarding recognising dying and communication with families.

  • Timely symptom control was being achieved by collaborative working.

  • Patients in residential settings often had limited input from specialist palliative care.

Conclusion The data highlighted some excellent examples of care, and also identified some areas of improvement to action which included:

  • Advocating earlier referrals into the hospice, ACP discussions and use of the electronic palliative care register.

  • Recommending ACP is reviewed and updated regularly particularly RAG status when patients are deteriorating.

  • Promoting clear documentation specifically regarding communication with family members.

  • Encouraging early referral to the hospital palliative care team for patients admitted to an acute hospital to enable timely assessment.

  • Promoting specialist palliative care services within local residential homes with support from the hospice education team.

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