Landmark learning-from-deaths guidance launched

Press release
26 November 2018

The first-ever national guidance for NHS mental health trusts to ensure ways of improving services are learned from patients’ deaths is unveiled today.

The guidance, drawn up by the Royal College of Psychiatrists (RCPsych), focuses on patients with severe mental illness and on four ‘red-flag’ scenarios, including where concerns have been raised by families and carers or where patients have experienced psychosis or had an eating disorder.

To ensure any opportunities for learning are not missed, trusts are also encouraged to review a sample of other patients’ deaths, such as those with dementia.

The most serious examples of care failings in NHS mental health services are already dealt with under Serious Incident investigations.

But concerns were raised over the handling of other patient deaths in 2015 after it emerged that in the case of one trust, Southern Health, more than 1,000 patients with learning disabilities or mental health problems over four years had not been properly investigated. The probe followed the death of teenager Connor Sparrowhawk, who had autism.

RCPsych has now drawn up national guidance, which is made up of a Care Review Tool and guidance on how to use it, for the first time at the request of NHS England.

Dr Adrian James, the College’s Registrar, who has been closely involved in the year-long project, said:

“This is a really important piece of work. Around 2.5 million people are in contact with secondary mental health, learning disabilities and autism services each year and the deaths of many patients will be unconnected to the care they received1.

“But it is crucial that ways of improving services are learned from patients’ deaths. Our guidance offers those services a great opportunity to do exactly that.

“The Royal College of Physicians has drawn up a similar process for general hospitals and we’d really like to see funding given to roll out training in how our guidance can best be used at mental health trusts across the country and to flag up and spread learning from it both locally and nationally.”

Liaison psychiatrist Dr Elena Baker-Glenn, from Cambridgeshire and Peterborough NHS Foundation Trust, led on the development of the Care Review Tool, which is a two-stage process and involves filling out a form.

First, deaths are selected for screening to see whether they need to be reviewed more closely.

Section one of the form, which should be filled in soon after the patient’s death, includes their details and the four ‘red-flag’ scenarios which should prompt further investigation.

Those four scenarios, which focus on patients likely to have severe mental illnesses like bipolar disorder or anorexia, are:

  • where concerns have been raised about the patient’s care by their families, carers or staff
  • where the patient has experienced psychosis or an eating disorder during their last episode of care
  • where the patient was recently admitted to a psychiatric ward
  • where the patient was under the care of a crisis and home treatment team at the time of their death.

Secondly, if any of these four scenarios apply, then an experienced clinician at the trust, who was not involved in the patient’s care, is asked to go through their case notes and rate their care as either “excellent”, “good”, “adequate”, “poor” or “very poor” and include a written explanation of how they came to that conclusion within 60 days.

One of RCPsych’s research arms, the College Centre for Quality Improvement, has piloted the guidance at 11 mental health trusts and consulted with families and carers.

Thousands of people in contact with mental health trusts die each year, with many of those deaths unconnected to the care they received. So a trust will not be expected to review all patients’ deaths; instead they are advised to look at those which meet the essential criteria as well as reviewing a sample of other deaths.

The guidance has proved incredibly successful at trusts involved in the pilot project.

One trust, Leeds and Yorkshire Partnership NHS Foundation Trust (LYPFT), reviewed the deaths of 20 dementia patients in care homes and found it was taking up to two weeks for its staff to visit the homes following reports of violent behaviour by residents.

The review process also identified an issue around dementia patients being discharged from hospital who were on anti-psychotic drugs but not under the care of a psychiatrist.

Professor Wendy Burn, RCPsych President and an old-age psychiatrist at LYPFT, said:

“I was really impressed with how using the guidance identified potential issues with how we look after our patients.

“It highlighted areas where we could improve the care we give. These issues may not have been flagged up otherwise. There is potential for learning to be shared on a national basis which would be a big step forward.”

Another trust, Mersey Care, found that the guidance much more quickly identified the patients’ deaths which most warranted review. By using it, it took only around 40 hours of dedicated time a month to identify those cases compared to around 100 hours a month under their old system.

Dr Panchu Xavier, associate medical director – learning reviews at Mersey Care NHS Foundation Trust, said:

“The College’s guidance has been extremely effective. We found that the red-flag system highlighted all the most pressing cases and is saving us hundreds of hours of staff time.”

The guidance, which can also be used to inform how trusts respond to patients and carers about concerns they’ve raised about their loved ones’ care, is not mandatory. NHS England provided £35,000 to fund the work.

Minister for Care Caroline Dinenage said:

“Each preventable death is a tragedy and we must learn from every one. This new guidance will equip trusts with the tools to more quickly identify areas of improvement, provide more support for families and implement changes to better care for people with severe mental health conditions.

“It represents another significant step forward in improving safety for patients across the country and safeguarding the most vulnerable in their time of need.”


1. NHS Digital: Mental Health Bulletin: 2016-17 Annual Report

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