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In 2016, a Care Quality Commission review found that opportunities to learn from deaths were missed.1 2 The National Quality Board published guidance,3 the Structured Judgement Review (SJR) being a recommended tool in the review of adult deaths undertaking qualitative analysis of mortality data using a standardised validated approach.
An SJR comprises five sections. This letter looks at one subsection of phases of care, end-of-life care (EOLC). Reports from relatives/loved ones, significant concerns raised by staff, patients with learning disabilities or severe mental illness, cases which are serious incidents requiring investigation require an SJR in Oxford. Reviewers should be familiar with the working practices of the clinical area and independent of the care under scrutiny. A score for the EOLC phase of care will range from 1 (very poor) to 5 (excellent) and will be supported by written justification of the score.
In 2018/2019, 96% of SJRs in Oxford found the EOLC phase to be good or excellent. This was out of step for the scores for other phases (range 50%–75% rated good or excellent) and did not identify any learning. A review of deaths in patients with cancer also found that the recorded quality of the EOLC phase in SJRs …
Contributors DL and AL undertook the review in 2018/2019. SY and MM undertook the review in 2019/2020. MM wrote the article. AL and SY reviewed the article.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.