News and presentations from today's conference focusing on improving investigation and learning from deaths in NHS Trusts; reflecting on learning from deaths during the Covid pandemic and how mortality investigation should be managed in these cases, the role of Medical Examiners in learning from deaths, and the new National Patient Safety Incident Response Framework.
EXTENDED SESSION: Learning from deaths during Covid-19
Ellen Makings Regional Medical Examiner
East of England
• learning from deaths
• ensuring learning from the mortality review process, incidents and investigations leads to sustainable improvements in quality or safety
• learning from Covid-19
• developing the role of the Medical Examiner
• extending medical examiner scrutiny to all non-coronial deaths wherever they occur
• our experience
Ellen gave a national update covering the role of the Medical Examiner, why we need them, what they do and how they support learning from deaths. She said it is important to ensure the Medical Examiner is correctly scrutinising and there is governance in place, she said Medical Examiners are professionally accountable to the National Medical Examiner via their Regional Medical Examiner. The Medical Examiner can raise a severe concern with the Coroner to investigate. For far less severe concerns the Medical Examiner may invite the ward team to meet with the family and refer the family to PALS.
Ellen discussed the implications of Covid-19 for the Medical Examiner, and gave an update of non-acute roll out and Medical Examiners taking on their local community deaths. Ellen described how this works in practice based on their experience of 1900 community deaths assigned to the Royal Papworth Medical Examiner office. Considerations included data sharing and access to GP notes.
Working with and involving families when an death occurs
Julian Hendy Founder, Hundred Families
Co Founder & Member, Making Families Count
• learning from the lived experience
• how can we put patients and carers at the heart of the process?
• how excellent family engagement can produce better results for family and Trust during serious incident investigations
• involvement in reviews and investigations: what does excellence look like?
• implementing the new national guidance in practice
• developing the role of the Family Liaison Officer; what type of cases should be referred to the FLO and when the FLO can’t assist
Julian shared his experience of working with and supporting bereaved families, since losing his own dad. He said it is important to ensure learning happens and that it is embedded. Families should be at the centre of this. He said saying sorry isn't an admission of responsibility but it shows you care, it's the first step to learning what happened.
Working with the Coroner: death notifications, coronial investigation, inquest & Preventing Future Deaths
Nadia Persaud Senior Coroner
Eastern Area of London
• notification of deaths to Coroner, MCDs and Working with the medical examiner
• the coroner’s investigation
• what is an unnatural death and opening an inquest
• interested Persons and the Inquest
• learning from deaths: Preventing Future Death Reports
Resources:
https://www.england.nhs.uk/patient-safety/serious-incident-framework/
Revised guidance for registered medical practitioners on the Notification of Deaths Regulations March 2020