Deaths caused by problems in care       

FOI REFERENCE: 24208    FOI DATE: 4^th July 2024      

 1) Please tell me separately for 2022/23 and 2023/24 the number of deaths for which a case record review or investigation has been carried out leading to the conclusion that they were more likely than not to have been due to problems in the care provided to the patient.

All incidents where the outcome was patient death

2022-23: 51 incidents reported

2023-24: 80 incidents

Incidents that warranted a full investigation (SIs)

2022-23: 37

2023-24: 33

NOTE: I understand that one widely used method for determining this is the Royal College of Physicians’ Structured Judgement Reviews (SJR) 1-6 system. If this system was used, by “more likely than not” I’m referring to cases with scores of 3 (probably avoidable), 2 (strong evidence of avoidability) and 1 (definitely avoidable). 

2) Please provide me with a brief overview of the FIRST FIVE incidents (in 2023/24 preferably or from 2022/23 if the former is not yet available) identified in question 1 (i.e. cases of deaths that were more likely than not caused by problems in care), withholding any identifying information that would run into a Section 40 exemption.

The Trust does not record death incidents directly related from deficiencies in care and it would require a manual search, review and audit of all serious incidents reports. We perform Structured Judgement Reviews which do not grade deaths in terms of ‘avoidability’ as we have found that this is not robust, and open to challenge and causes confrontation instead of presenting opportunities for learning.
 
3) Finally, can you please summarise what the Trust learnt and what actions have been taken as a result of these five cases highlighted in question 2? See Above