Trust performance & learning from deaths
2019/20
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Indicator |
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Q1 |
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Q2 |
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Q3 |
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Q4 |
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Year End |
Learning Points |
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Patient Safety: Total percentage inpatient deaths subject to a case record review |
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100% |
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100.00% |
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100% |
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Patient Safety: Total number of in-patient deaths subject to a case record review identifying that there was a problem in care provided |
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1 |
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1 |
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2 |
Serious incident reviews have been undertaken. The learning will be provided in the next Learning from Experience report Trimester 2, 2019/20 |
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Patient Safety: Total percentage of deaths reported by and to the Trust(including inpatient deaths)subject to a case record review |
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100% |
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97% |
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99% |
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Patient Safety: Total number of deaths (including inpatient deaths) subject to a case record review estimated due to problems in care |
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0 |
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0 |
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0 |
In response to the high number of case record reviews resulting in no problems in care, the clinical audit programme will be increased from 5% to audit 10% of reviews from April 2019. |
2018/19
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Indicator |
Q1 Apr-Jun |
Q2 Jul-Sep |
Q3 Oct-Dec |
Q4 Jan-Mar |
Year End | Learning Points | |||||
| Patient Safety: Total % inpatient deaths subject to a case record review | 100.00% | 100.00% | 100.00% | N/A | 100% | Learning points identified (Requirement from Q3): Apr-17: Referral pathways implemented for long term conditions to inform specialist nursing/medical care. July-17: Improved safer transfer of patient care between CWP and acute trust. |
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| Patient Safety: Total number of inpatient deaths subject to a case record review identifying that there may have been a problem in the care provided | 1 | 2 | 0 | N/A | 3 | ||||||
| Patient Safety: Total % deaths reported by and to the Trust (including inpatient deaths) subject to a case record review | 15% | 17% | 18% | 20% | 18% | Learning points identified (Requirement from Q3): Oct-17: Need to review adequacy of systems to reliably contact the District Nursing Service out of hours. Nov-17: Improvements required to communication with families in relation to medication regimens in place for people receiving palliative care. |
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| Patient Safety: Total number of deaths (including inpatient deaths) subject to a case record review identifying that there may have been a problem in the care provided | 0 | 2 | 2 | 0 | 4 | ||||||
2017/18
You can read the Trust performance 2017/18 report here.
| Indicator | Q1 Apr-Jun |
Q2 Jul-Sep |
Q3 Oct-Dec |
Q4 Jan-Mar |
Year End | Learning Points | |||||
| Patient Safety: Total % inpatient deaths subject to a case record review | 100.00% | N/A | N/A | N/A | 100% | N/A | |||||
| Patient Safety: Total number of inpatient deaths subject to a case record review identifying that there may have been a problem in the care provided | |||||||||||
| Patient Safety: Total % deaths reported by and to the Trust (including inpatient deaths) subject to a case record review | 34% | 54% | |||||||||
| Patient Safety: Total number of deaths (including inpatient deaths) subject to a case record review identifying that there may have been a problem in the care provided | |||||||||||
You can read the Trust performance 2018/19 report here.
Click here to see the Learning from Experience report – trimester 3 2017/18