QSPOL14 Mortality Review Policy v3 by Provide Community

Mortality Review Policy Learning from Deaths

Version: V3

Ratified by: Mortality Review Group

Date ratified: 24/11/2022

Job Title of author: Head of Quality and Safety

Reviewed by Committee or Expert Group Mortality Review Group

Equality Impact Assessed by: Head of Quality and Safety

1. Introduction

Death is an inevitable outcome of people’s lives and some of these will occur whilst in the care of Provide Community Group services. Health and social care staff work tirelessly to deliver safe, high-quality care. A few patients experience poor quality care, sometimes resulting from multiple contributory factors.

It is therefore essential to:

• Review the quality of care nearing or at the time of death.

• Assess if death in health and social care settings was avoidable or due to problems in the service delivery, leadership or wider system failures.

Reviews and investigations must lead to actions and shared learning to prevent recurrence.

This overarching policy is for all deaths that occur whilst under the care of services within Provide Community Group, to cover all:

• Death of Adults >18 years

• Death of People with Learning Disabilities & Autism

• Death of Children <18 years

2. Purpose

The purpose of this policy is to describe the framework for reviewing incidents of mortality, undertaking actions to improve care and share learning and best practices, and should be read in conjunction with the following policies, guidelines and commissioning intentions. These include:

• QSPOL01 Incident Reporting and management Policy

• QSPOL03 Being Open and Duty of Candour Policy.

• CSPOL01 Complaints and Compliments Policy.

• SGSOP16 Child Death Review

• SGSOP14 Serious Case Review, Safeguarding Adult Review & Domestic Homicide Review.

This policy applies to all employees working within Provide Community Group including:

• Temporary staff working as Bank, Locum and Agency

• Staff holding honorary contracts

• Independent contractors.

3. Definitions

Patient

Mortality Review

Structured Judgement Review Methodology (SJR)

Patient Safety Incident

Notifiable Safety Incident (Serious Incident)

This term is used generically within this document but includes customers, service users, clients, residents as applicable to the health or social care setting in which they were cared for.

The process of reviewing the quality of care and assessing if the incident of patient death was avoidable against the Structured Judgment Review (SJR) methodology.

Method of reviewing the quality of care and the degree of avoidability of patient death developed by the Royal College of Physicians 2016.

Any health or social care related event that was unintended, unexpected and undesired and which could have or did cause harm to patients

Is defined as an incident that occurred resulting in one of the following:

• Unexpected or avoidable death of one or more patients, staff, visitors or members of the public

• Serious harm to one or more patients, staff, visitors or members of the public or where the outcome requires life-saving intervention, major surgical/medical intervention, permanent harm or will shorten life expectancy or result in prolonged pain or psychological harm

• Allegations of abuse; adverse media coverage or public concern about the organisation or the wider health and social care organisations

• One of the core set of Never Events defined by NHS England https://www.england.nhs.uk/wpcontent/uploads/2020/11/Revised-Never-Events-policyand-framework-FINAL.pdf

Notifiable incidents are subject to more rigorous scrutiny in terms of reporting, investigation and learning.

Significant Event

Duty of Candour

Unlike the other definitions, a significant event is not a nationally recognised classification of an adverse incident, but a classification within the Organisation.

This relates to incidents that do not meet the criteria for reporting as Serious Incidents, but where the organisation identifies that a more in-depth analysis of an incident may result in valuable learning

Duty of Candour is defined as a professional responsibility to be open and honest with patients and people when things go wrong with their treatment or care

4. Duties

The Chief Executive Officer and Board

Has overall accountability for ensuring that the organisation has robust policies and procedures in place for reviewing all agreed categories and incidents of mortality in scope and that these are appropriately reviewed and where required appropriate actions taken and learning shared.

Quality and Safety Committee

The committee has responsibility for ensuring compliance with all legal, statutory, best practice and quality requirements and for ensuring employees have good quality, ratified procedural documents to work with.

The committee will ensure there are robust systems in place for recognising, reporting, reviewing or investigating deaths and actions are completed and the learning shared where there have been problems in care.

The committee will ensure systems and processes are adequately resourced

Chief Officers and Non-Executive Directors

Should have the capability and capacity to understand the issues affecting mortality in their Organisation and provide necessary challenge.

The Mortality Review Group

As a subcommittee of the Quality and Safety Committee meet quarterly and consists of an appropriately selected group as defined by the Terms of Reference.

The Mortality Review group review a selection of deaths per quarter using the Structured Judgement Review Methodology as outlined below and following the Flow chart in Appendix 1. Deaths are selected for review via a random selection of deaths data or where further review is requested for quality assurance oversight

The Group ensure that learning from reviews and investigations is acted upon to disseminate recommendations for change to clinical and organisational practice and improve care and incidence of mortality Reviews, investigations and learning is reported at the Quality Professional Leadership Team Meeting (QPLT) which feeds into the Quality and Safety Committee and to the Board.

Quality assurance of mortality reviews will be carried out as part of the Quality and Safety audit cycle.

Assistant Directors/Directors/Managers

Are responsible for ensuring there are arrangements for reviewing all agreed incidents of mortality in scope and where required appropriate actions are taken and learning shared. Assistant Directors will identify appropriately trained investigators from peer teams within Provide Group to undertake the reviews.

The Head of Quality and Safety

Is responsible for the coordination and management of Significant Events around unexpected deaths, ensuring actions are taken and learning shared through their Service Delivery Unit and Quality and Safety meetings.

The Business Intelligence Team

Are responsible for creating and reporting accurate mortality data in line with the policy scope and liaising with the Assistant Directors and Head of Quality and Safety.

5. Scope and Rationale for Mortality Reviews

Provide Community Group provides a range of community and inpatient/residential services across health and social care settings for children and adults.

Deaths where there are suspicious circumstances will be under the auspices of the Coroner, Police or statutory reviews and will be reviewed through Domestic Homicide or Safeguarding Adult Review processes.

The Mortality Review Group will continually review patients in scope to ensure reviews are appropriate and proportionate to the services that Organisation provides

Appendix 2 provides guidance to Patients in Scope for Review or Investigation.

Staff should refer to the Medical Advisor or the Head of Quality and Safety for clarification whether a review or investigation is required if it appears to be outside of the scope of this Section.

6. Child Death Reviews (See SGSOP16)

Chapter 5 of Working Together to Safeguard Children, 2018 sets out the statutory responsibilities of the Child Death Review (CDR) partners, who are local authorities and any clinical commissioning groups for the local area as set out in the Children Act 2004 and amended by the Children and Social Work Act 2017.

Following the unexpected death of a child the Designated Paediatrician should then decide on whether or not a rapid response is required based on their professional judgement, the information available to them at the time and liaison with the Coroner The decision to initiate the CDR process will then be made. These will be investigated through a Local Child Death Review Group and feedback where relevant to Provide reported via the Safeguarding Teams Quarterly report to Quality and Safety Committees.

Following the unexpected death of a child known to Provide Services, Practitioners who have been working with the family will be identified by the Safeguarding Team and may be contacted by the eCDR Administrator for information sharing prior to the review. Please see process map in Appendix 3

7. Learning from Lives and Deaths- people with a Learning Disability and autistic people (LeDeR)

Research has shown that on average, people with a learning disability and/or autism die earlier than the general public, and do not receive the same quality of care as people without a learning disability/autism. The LeDeR programme reviews deaths of people with Learning disabilities and autism to see where services can be improved to prevent early deaths.

From June 2021 All deaths for people with Learning disabilities and Autism will be reviewed following notification via the LeDeR website. This is now the responsibility of the ICBs as this will enable local rather than national issues to be addressed.

See https://www.england.nhs.uk/publication/learning-from-lives-and-deaths-peoplewith-a-learning-disability-and-autistic-people-leder-policy-2021/

To report any deaths of people with a Learning Disability or Autism access the online portal at: https://leder.nhs.uk/ and click on:

8. Learning

Learning is the critical process for improving the quality of patient care. Provide will ensure it shares and acts upon learning from reviews and investigations within and across Provide Community Group and across the wider health economy including the independent Health and Social Care services.

9. Supporting Bereaved Families and Carers

It is a priority to work closely with bereaved families and carers to ensure a consistent level of timely, meaningful, and compassionate support and engagement at every stage - from notification of death, primary review or investigation to completion of an investigation report and lessons learned and actions taken.

Bereaved family and carers must be given the opportunity to raise questions or share concerns in relation to the quality of care received by their loved one and be informed of their right to raise concerns about the quality of care provided. Families will be sign posted to the local bereavement services and specialist centres as appropriate.

Appendix 4 offers further guidance on the support bereaved families and carers should receive.

10.Structured Judgement Review Methodology

There are a number of national methods for calculating standardised mortality ratios. The two most commonly recognised national mortality indicators are:

• Hospital Standardised Mortality Ratio (HSMR)

• Summary Hospital Mortality Indicator (SHMI

Although both of these indicators have significant value for measuring mortality rates in Acute Hospital settings, it is problematic to apply these methodologies to community organisations, as acute trusts typically have a high volume of short stay patients, with low risk of mortality in contrast to the nature of patients and clinical services of community organisations.

Provide Community Group provides a range of inpatient/residential and communitybased services for children and adults within health and social care settings.

To support an appropriate and robust approach to mortality surveillance the Organisation has adopted the Structured Judgment Review (SJR) methodology developed by Royal College of Physicians in accordance with the guidance from the National Quality Board.

The Structured Judgement (Mortality) Review is a five-outcome scale for assessing the quality of care approaching or at the time of death

See Appendices:

Appendix 5: Inpatient, Community Hospital Structured Judgement (Mortality) Review Proforma.

Appendix 6: Community Services Structured Judgement (Mortality) Review Proforma.

NB An outcome of 1 or 2 must be reported to the relevant Assistant Director for the appropriate management of the incident.

Outcome of Mortality Reviews and Investigations

The outcome of mortality reviews and investigations will be recorded through the Mortality Review Group action log and meeting minutes. These will be retained by the Quality and Safety team.

11.Process

Please refer to Provide’s learning from deaths flowchart in Appendix 1

Mortality reviews and investigations must be assessed against the Organisation’s policies and procedures and professional standards. In many circumstances, more than one organisation may be involved in the care of a patient and where problems are identified relating to other organisations, it is important the relevant organisations are informed, so they can undertake any necessary investigation and actions.

The organisation will consider as appropriate whether they can routinely arrange joint reviews or investigations for individuals or groups of patients where more than one organisation is providing care at the time of death.

The Mortality review Group Chair will randomly select at least 4 deaths for review from the data list. Deaths that had also been flagged via the Group incident reporting systems may also be selected for panel review as part of the learning from deaths and quality assurance processes.

The Assistant Director for the service will delegate the review to an appropriate peer reviewer who will complete the review using the appropriate Structured Judgement Review document.

The Mortality Review Group will regularly monitor the completeness and quality of all reviews at each meeting

All Mortality Reviews should be reviewed against the Datix system records ensure there were no related concerns (incidents/risks/complaints) that may impact the decision making and outcomes of the Mortality review process.

12. Training and Competencies

A range of training opportunities are available including Investigation Skills and Root Cause Analysis training to support staff with completing Mortality Reviews. Bereavement support training and communication skills training can be accessed upon request via Learning & Development and Line Managers. All staff have access to Clinical Supervision. Guidance and support is also available from the Quality and Safety Team throughout the process.

All new members of staff will be introduced to the principles of compassionate and values-based care relating to risk management during their Corporate and Local induction, including reporting significant events/serious incidents during their employment with Provide Group

Appendix 1: Learning from Deaths – Mortality Review Process

For all deaths aged 18 and over and fall within the scope of the Learning from deaths policy. This procedure does not apply to learning disability/autism deaths and child deaths as those follow the LeDeR and child death review process.

Arandomselectionofdeathsthatfallunderthescopeofthelearningfromdeathspolicywillbeidentifiedtobereviewed. Anydeaths highlightedthroughincidentreportingorviaotherreportingsystemsmaybeselectedforreviewbythepanel.

HeadofQualityandSafetywilldisemminatepatientdetailstotheappropriateAssistantDirector(AD)whowilldelegatetoan appropriatepeerreviewer.

Reviewercompletesprocesswithin2weeks (datetobeagreedwithADandHeadofQualityandSafety)ofrecievingpatientdetails usingthestructuredjudgementreviewmethodology.TheAssistantDirectormustensurereviewerhasaccesstotheappropraiteS1 unit.

TheReviewerwillreviewthepatientdetailsagainsttheDatixSystemtoensure allelementsthatmayhaveaffectedqualityofcare deliveryarereviewedduringtheprocess.

Reviewerreturnscompletedreviewtothe AssistantDirector bytheagreeddate.

Reviewerand/ortheAssistantDirectorspresentmortalityreviewsforeachpatientattheQuarterlyMortalityreviewgroup.

MortalityReviewpaneltoreviewprocess,themes,analysis ofeachpatientdeath.

MortalityReviewPanelmayrequestfurtherinformationfromntheclinicalrecordorelsewhereinoredertomakeathoroughreview

Moralityreviewpaneltorecommendactions andkeylearningpoints.Keylearningthroughdeathsissharedthroughoutorgansiation viapolicyreview,,teambriefingsororganisationalcommunications.

Mortalityreviewgroupidentifiesif apatientdeathrequires considerationforamoredetailedinvestigation-followincident managementpolicy

AssistantDirectorwilltakeaviewwhetherpatientsrelatives recieveinformationregardingLearningfromDeathsprocedureforalldeathsaged18andoverandfallwithinthescopeofthe Learningfromdeathspolicy.Thisproceduredoesnotapplyto learningdisabilitydeathsandchilddeaths.Thesewillfollowthe LeDerandchilddeathreviewprocess.

Appendix 2: Scope of Patient Death requiring Mortality Review or further Investigation

Inpatient Community Hospitals Inpatient Adult Learning Disabilities/Autism

Unless the incident of mortality meets the criteria for a more detailed investigation, all community hospital inpatient deaths will meet the criteria for a structured Judgment Review.

Data for consideration will include all active cases that died within the reporting period and 28 days post discharge from the service.

All incidents of Adult Learning Disabilities/Autism

inpatient mortality will be reported via LeDeR for investigation through this process however may also be reviewed via the Serious Incident management Process if the circumstances fall within this scope.

Community Adult Learning Disabilities

All incidents of Adult Learning Disabilities/Autism

Community mortality will be reported via LeDeR for investigation through this process however may also be reviewed via the Serious Incident Process if the circumstances fall within this scope.

Community Adult Children, Young People and Families

All incidents of death will fall within the scope of section 6.0 for a Structured Judgment Review unless it has been determined that it meets the criteria for a Serious Incident Review process. Data for consideration will include all active cases that died within the reporting period.

Unexpected deaths in children (0-18) follow a rapid response process, under the Child Death Review Statutory and Operational Guidance (England) HM Government 2018

If any of the unexpected deaths occurred as a result of any care provided by Provide Group Services the Serious Incident process will be instigated.

All child death (0-18) (expected and unexpected) are reviewed at the Child Death Review Panel which is a sub-group of the LSCB. See Appendix 3

Data will include these figures within the Mortality Review process for reporting only and within Safeguarding Reporting Processes.

Appendix 3: eCDOP CDR REVIEW PROCESS

Provide.safeguarding@nhs.net receive email notification of Child Death from CHIS/eCDOP

SG Admin records information onto CDR TRACKER noting Ref No and Case No R:\Clinical Quality\Safeguarding\Child Safeguarding\Child Death

SG Admin sends email to CHIS to advise of Child Death( if not already aware).

SG Admin checks SystmOne to ascertain which PROVIDE Services have delivered care to the Child within the last 3 years. NB guidance: SG Admin to alert SG Team if the child has any current safeguarding concerns or has been known to Provide Services within the last 5 years where there were safeguarding concerns.

SG Admin sends email to eCDOP administrator CDR.notifications@nhs.net with a list of email addresses of practitioners involved in care with a request for the Child Death Information to be sent directly to these named staff.

CHILDREN’S SAFEGUARDING NURSE AND/OR MEMBER OF THE TEAM IS COPIED INTO EMAIL

SG Admin emails relevant practitioners with copy to Team Lead, to advise they will be contacted by eCDOP regarding the child’s death. The email requests that action is taken promptly to access the portal and complete information required. Practitioners should download a printed copy of the finalised form and email it to Provide.safeguarding@nhs.net to advise this has been completed.

CHILDREN’S SAFEGUARDING NURSE AND/OR MEMBER OF THE TEAM IS COPIED INTO EMAIL

SG Admin updates the spreadsheet with names of all Provide Clinicians involved in care and date to send ‘reminder emails’ to Practitioners if required when ‘completion emails’ are not received.

If the child is not known to Provide Services, the SG Administrator will register the child to the safeguarding unit and inform a member of the Safeguarding Team. They will then email the Child Death Review Team CDR.notifications@nhs.net Child Death Review Manager (01992 566131) and let them know the child is unknown to any of Provide services and advise the SG Administrator when this has been completed.

On receipt of email from practitioner confirming they have actioned the eCDOP request, the email should be forwarded to the SG Team Member dealing with the CDR Notification. The spreadsheet can be updated. The individual practitioners will be responsible for completing the eCDOP information request form, printing a copy of the form and emailing it to: provide.safeguarding@nhs.net to make them aware the request is complete . Quality Assurance will be carried out by the SG Team by quarterly random dip sample of completed CDR forms

Appendix 4: Support for Bereaved Families

1 It is of prime importance to work closely with bereaved families and carers to ensure a consistent level of timely, meaningful and compassionate support and engagement at every stage – from notification of death, investigation, investigation report, lessons learned and actions taken.

2 Dealing respectfully, sensitively and compassionately with families and carers of dying or deceased patients is crucially important. The principles of openness, honesty and transparency as set out in the Duty of Candour must be applied in engagement and involvement with bereaved families and carers.

3 The key principles for supporting bereaved families and carers are:

• To be treated as equal partners following a bereavement.

• To always receive a clear, honest, compassionate and sensitive response in a sympathetic environment.

• To provide a high standard of bereavement care which respects confidentiality, values, culture and beliefs, including being offered or signposted to appropriate support. This includes providing, offering or directing people to specialist suicide bereavement support.

• To be informed of their right to raise concerns about the quality of care provided to their loved one.

• To offer guidance, where appropriate, on raising a concern/complaint.

• For their views to help inform decisions about whether a review or investigation is needed.

• To receive timely, responsive contact and support in all aspects of an investigation process, with a single point of contact or liaison.

• To be partners in an investigation to the extent, and at whichever stages, that they wish to be involved, as they offer a unique and equally valid source of information and evidence that can better inform investigations.

Support can include:

• Support during and following an investigation. This may include counselling or signposting to suitable organisations that can provide bereavement or post-traumatic stress counselling, with attention paid to the needs of young family members, especially siblings.

4 People who are bereaved need others to recognise and acknowledge their loss. Recognition by professionals, appropriately expressed, may be particularly valued. Communication at the time of a death and afterwards, should be clear, sensitive and honest. Bereaved families and carers should be given as much information as possible in line with the Duty of Candour for providers. Every effort should be made to hold these discussions in a private, sympathetic environment, without interruptions.

5 When reviewing or investigating possible problems with care, involvement of bereaved families and carers begins with a genuine apology. Saying sorry is not an admission of liability and is the right thing to do. The appropriate staff member should be identified for each case, including to explain what went wrong promptly, fully and compassionately. This may include clinicians involved in the case but this may not always be appropriate and should be considered on a case by case basis.

6 Depending on the nature of the death, it may be necessary for several organisations to make contact with those affected. This should be discussed with the bereaved families and carers and a co-ordinated approach should

be agreed with them and the organisations involved. If other patients and service users are involved or affected by the death, they should be offered the appropriate level of support and involvement.

7 The Organisation should ensure that the deceased person’s General Practitioner is informed of the death and provided with details of the death as stated in the medical certificate at the same time as the family or carers. The GP should be informed of the outcome of any investigation.

8 Where a death is investigated under the Serious Incident Policy, early contact should be made with bereaved families and carers so that their views help to inform the decision.

9 Bereaved families and carers will expect to know: what happened; why it happened; and what can be done to stop it happening again to someone else. If the Organisation proceeds with an investigation, skilled and trained investigators need to be able to explain to bereaved families and carers the purpose of the investigation which is to understand what happened. If problems are identified, the investigation should be clear why and how these happened so that action can be taken to prevent the same problems from occurring again.

10 If a family wants to engage or contribute to an investigation, an early meeting should be held to explain the process, how they can be informed of progress, what support processes have been put in place and what they can expect from the investigation. This should set out realistic timescales and outcomes. There should be a named person as a consistent link for the families and carers throughout the investigation.

11 Bereaved families and carers should:

• Be made aware, in person and in writing as soon as possible, of the purpose, rationale and process of the investigation to be held.

• Be asked for their preferences as to how and when they contribute to the process of the investigation and be kept fully and regularly informed, in a way that they have agreed, of the process of the investigation.

• Have the opportunity to express any further concerns and questions and be offered a response where possible, with information about when further responses will be provided.

• Have a single point of contact to provide timely updates, including any delays, the findings of the investigation and factual interim findings. This may disclose confidential personal information for which consent has been obtained, or where patient confidentiality is overridden in the public interest. This should be considered by the organisation’s Caldicott Guardian and confirmed by legal advice in relation to each case.

• Have an opportunity to be involved in setting any terms of reference for the investigation which describe what will be included in the process and be given expectations about the timescales for the investigation including the likely completion date.

• Be provided with any terms of reference to ensure their questions can be reflected and be given a clear explanation if they feel this is not the case.

• Have an opportunity to respond on the findings and recommendations outlined in any final report; and,

• Be informed not only of the outcome of the investigation but what processes have changed and what other lessons the investigation has contributed for the future.

Learning, Candour and Accountability, Care Quality Commission, December 2016

Appendix 5: Structured Judgement Review (SJR) Template Inpatients/Community Hospitals

Patient’s Name:

NHS No:

Male/Female: Age at Death:

Source of Admission: Date of Death:

Date of Admission: Reason for Admission: Ward: Business Unit:

Risk Factors

Did the patient have a Learning Disability? Tick as appropriate. Yes  No

If Yes, complete review and forward the completed review to the Provide’s Learning Disability Lead for the Management into the Learning Disabilities Mortality Review programme.

Recorded Cause of Death: Diagnosis:

Cancer Diagnosis: Tick as appropriate: Yes  No

If no, did death occur within 30 days of receipt of active cancer treatment?

Tick as appropriate: Yes  No

Mental Health Act (MHA) Status

Was the patient subject to the MHA/DoLS? Tick as appropriate Yes  No

If Yes, record status:

Were there any problems with the care of the patient or incidents?

Tick as appropriate and comment if Yes. Yes  No

Record you explicit judgment/statements about the quality of care the patient received and whether it was in accordance with the Organisation procedures/good practice.

If there is any other information that you think is important or relevant that you wish to comment on then please do so.

Please score each area of the review using the scale below

Admission and Initial Management, (The first 24 hours)

Ongoing Care

Care during a procedure ( excluding IV cannulation)

Perioperative Care

End Of Life Care

Overall Assessment

Care  5=Excellent  Tick as appropriate.

NB Outcomes of 1 or 2 must be recorded and the Head of Quality and Safety informed for the appropriate management of the incident.

Points for Shared Learning and Actions

Multidisciplinary SJR completed by: (List all staff involved. Minimally must be two members of staff).

Team completing review: Date:

Level of Harm (to be completed following panel review process)

Panel Decision:

Compiled referencing National Mortality Case Record Review Programme Royal College of Physicians 2017

Appendix 6: Structured Judgement Review (SJR) Template Community Patients

Patient’s Name:

Male/Female:

Source of Admission:

Date of Admission:

NHS No:

Age at Death:

Date of Death:

Reason for Admission: Team: Business Unit:

Known Location of patient’s death: Tick as appropriate.

Home  Acute Trust  Hospice 

Residential/Nursing Home  Out of county placement  Other 

Risk Factors

Did the patient have a Learning Disability? Tick as appropriate: Yes  No

If Yes, complete review and forward the completed review to the Provide’s Learning Disability Lead for the Management into the Learning Disabilities Mortality Review programme.

Recorded Cause of Death:

Diagnosis:

Cancer Diagnosis: Tick as appropriate: Yes  No

If no, did death occur within 30 days of receipt of active cancer treatment? Tick as appropriate: Yes  No

Mental Health Act (MHA) Status

Was the patient subject to the MHA/DoLS? Tick as appropriate Yes  No

If Yes, record status:

Were there any problems with the care of the patient or incidents?

Tick as appropriate and comment if Yes. Yes  No

Record your explicit judgment/statements about the quality of care the patient received and whether it was in accordance with Organisation procedure/good practice.

If there is any other information that you think is important or relevant that you wish to comment on then please do so.

Please score each area of the review using the scale below

1= Very Poor Care 2= Poor Care 3= Adequate Care 4= Good Care 5= Excellent Comment Score Assessment, Initial Management, Care Planning, Interventions and Ongoing Care Contact with Families and Carers

End of Life Care

Overall Assessment Tick as appropriate.

NB: Outcomes of 1 or 2 must be recorded and the Head of Quality and Safety informed for the appropriate management of the incident.

Points for Shared Learning and Actions

Multidisciplinary SJR completed by: (List all staff involved. Minimally must be two members of staff).

Team completing review:

Date:

Level of Harm (to be completed following panel review process) Tick as appropriate:

Panel Decision:

Compiled referencing National Mortality Case Record Review Programme Royal College of Physicians 2017

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 1: ‘Screening’

Name of project/policy/strategy (hereafter referred to as “initiative”):

Mortality Review: Learning from Deaths Policy

Provide a brief summary (bullet points) of the aims of the initiative and main activities:

To hold reviews following the death of people open to Provide Community CIC Assess if the death was avoidable or due to problems with service delivery or wider system failure.

Disseminate any learning from the mortality reviews and change practice to ensure lessons are learnt to prevent recurrence.

Project/Policy Manager: Head of Quality and Safety

Date:16/11/22

This stage establishes whether a proposed initiative will have an impact from an equality perspective on any particular group of people or community – i.e. on the grounds of race (incl. religion/faith), gender (incl. sexual orientation), age, disability, or whether it is “equality neutral” (i.e. have no effect either positive or negative). In the case of gender, consider whether men and women are affected differently.

Q1. Who will benefit from this initiative? Is there likely to be a positive impact on specific groups/communities (whether or not they are the intended beneficiaries), and if so, how? Or is it clear at this stage that it will be equality “neutral”? i.e. will have no particular effect on any group.

Neutral

Q2. Is there likely to be an adverse impact on one or more minority/under-represented or community groups as a result of this initiative? If so, who may be affected and why? Or is it clear at this stage that it will be equality “neutral”?

Neutral

Q3. Is the impact of the initiative – whether positive or negative - significant enough to warrant a more detailed assessment (Stage 2 – see guidance)? If not, will there be monitoring and review to assess the impact over a period time? Briefly (bullet points) give reasons for your answer and any steps you are taking to address particular issues, including any consultation with staff or external groups/agencies.

Guidelines: Things to consider

Equality impact assessments at Provide take account of relevant equality legislation and include age, (i.e. young and old,); race and ethnicity, gender, disability, religion and faith, and sexual orientation.

The initiative may have a positive, negative or neutral impact, i.e. have no particular effect on the group/community.

Where a negative (i.e. adverse) impact is identified, it may be appropriate to make a more detailed EIA (see Stage 2), or, as important, take early action to redress this – e.g. by abandoning or modifying the initiative. NB: If the initiative contravenes equality legislation, it must be abandoned or modified.

Where an initiative has a positive impact on groups/community relations, the EIA should make this explicit, to enable the outcomes to be monitored over its lifespan.

Where there is a positive impact on particular groups does this mean there could be an adverse impact on others, and if so can this be justified? - e.g. are there other existing or planned initiatives which redress this?

It may not be possible to provide detailed answers to some of these questions at the start of the initiative. The EIA may identify a lack of relevant data, and that data-gathering is a specific action required to inform the initiative as it develops, and also to form part of a continuing evaluation and review process.

It is envisaged that it will be relatively rare for full impact assessments to be carried out at Provide. Usually, where there are particular problems identified in the screening stage, it is envisaged that the approach will be amended at this stage, and/or setting up a monitoring/evaluation system to review a policy’s impact over time.

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage 2:

(To be used where the ‘screening phase has identified a substantial problem/concern)

This stage examines the initiative in more detail in order to obtain further information where required about its potential adverse or positive impact from an equality perspective. It will help inform whether any action needs to be taken and may form part of a continuing assessment framework as the initiative develops.

Q1. What data/information is there on the target beneficiary groups/communities? Are any of these groups under- or over-represented? Do they have access to the same resources? What are your sources of data and are there any gaps?

Q2. Is there a potential for this initiative to have a positive impact, such as tackling discrimination, promoting equality of opportunity and good community relations? If yes, how? Which are the main groups it will have an impact on?

Q3. Will the initiative have an adverse impact on any particular group or community/community relations? If yes, in what way? Will the impact be different for different groups – e.g. men and women?

Q4. Has there been consultation/is consultation planned with stakeholders/ beneficiaries/ staff who will be affected by the initiative? Summarise (bullet points) any important issues arising from the consultation.

Q5. Given your answers to the previous questions, how will your plans be revised to reduce/eliminate negative impact or enhance positive impact? Are there specific factors which need to be taken into account?

Q6. How will the initiative continue to be monitored and evaluated, including its impact on particular groups/ improving community relations? Where appropriate, identify any additional data that will be required.

Guidelines: Things to consider

An initiative may have a positive impact on some sectors of the community but leave others excluded or feeling they are excluded. Consideration should be given to how this can be tackled or minimised. It is important to ensure that relevant groups/communities are identified who should be consulted. This may require taking positive action to engage with those groups who are traditionally less likely to respond to consultations, and could form a specific part of the initiative. The consultation process should form a meaningful part of the initiative as it develops, and help inform any future action. If the EIA shows an adverse impact, is this because it contravenes any equality legislation? If so, the initiative must be modified or abandoned. There may be another way to meet the objective(s) of the initiative.

Further information:

Useful Websites www.equalityhumanrights.com Website for new Equality agency www.employers-forum.co.uk – Employers forum on disability www.disabilitynow.org.uk – online disability related newspaper www.efa.org.uk – Employers forum on age

EQUALITY IMPACT ASSESSMENT TEMPLATE: Stage One: ‘Screening’