Learning from deaths

Trigger warning — this page inclues infromation about mental health and mortality

Caroline Donovan, Chief Executive at Norfolk and Suffolk NHS Foundation Trust: “Every death is a death too many and every person who has died has a family whose lives have been devastated from their loss.

“We can’t learn from these sad outcomes and experiences, and we can’t assess our performance and quality if we don’t know what’s happening to the people in our care.

“We now investigate and report on patient deaths, in public, to every board meeting.

“I do not underestimate how much pain and trauma bereaved families and relatives have been through and sincerely apologise that the Trust may have added to this pain by not accurately recording the circumstances surrounding the loss of their loved ones.

“I would like to share my sincere gratitude with the bereaved families and carers who have been working with us, for their invaluable challenge and support to help us get this right. We will continue to work closely with them to make sure we proceed to learn and become a safer, kinder and better organisation of the future.”

Learning from deaths

Working with service users, carers and bereaved families to make significant improvements on how we collect, analyse and report mortality data

Norfolk and Suffolk NHS Foundation Trust (NSFT) has a comprehensive improvement plan as part of our new vision and strategy to improve outcomes and experiences for our service users, families, carers and our staff. Our vision and strategy make it clear how all our work focuses on long term, sustained improvement to create a safer, kinder and better organisation.

One of our core transformation and improvement programmes within our strategy is focussed on learning from deaths, which is split into three clear areas of focus:

Collecting, analysing and reporting on deaths ; involving the creation of a new electronic system for mortality information collection, analysis and reporting.
Ensure learning through improvements to clinical practice ; reviewing all Prevention of Future Deaths reports from 2013 to identify themes and ensure learning and improvement, including themes from the Forever Gone Report, Domestic Homicide Reviews and Serious Case Reviews.
Work with service users, carers and bereaved families ; detailed work with service users, families carers and bereaved families who sit on our Learning from Deaths Action Plan Management Group.

How we process data

An example of how we process data:

How NSFT is notified of a death - NSFT has a new, automated database which came into use on 1 November 2023. A list of individuals who have passed away is updated daily with notifications of deaths from our Electronic Patient Record (EPR) systems and from a Service User Death Report (SUDR). The SUDR is a daily notification from a national NHS source of any deaths associated with the NHS patients. A patient’s GP is responsible for updating this national source of data. This information is shared safely and securely with us.
Someone passes away - It is always devastating when a loved one, family or friend passes away. This could be for a number of different reasons. NSFT’s new robust screening process receives notifications of every death for patients who died whilst open to NSFT services or within 6 months of their discharge. Every one of these is then manually screened to assess whether they meet the criteria for reporting as ‘Under NSFT care’. The system also identifies which care group the individual was receiving care from or which care group they were discharged from.
What we do and who we work with to assign information - When we receive these daily updates, a dedicated team of NSFT staff analyse the details of those who have sadly passed away. This team includes clinicians and experts who have vast experience of analysing complex information. Using our new system, we identify people that have passed away whilst open to NSFT services, or within six months of discharge from our services. For those records that are confirmed as being under NSFT care we then establish cause of death and categorise these into one of five categories.
How is the information assigned and why - Our five categories identify the cause of death of loved ones who have passed away. These categories are: expected natural, unexpected natural, unexpected unnatural, awaiting cause of death, unable to obtain cause of death. By using these categories, we are able to analyse the data and in particular, identify loved ones who passed away which could be related to the quality of care they received from our services.

What the data means

Below are the definition for how the data is categorised:

Expected natural cause of death

This is a death which has a clear natural cause. Examples may include a death linked to a neurological disease, such as Parkinson’s or dementia, frailty or old age, cancer and organ failure.

Unexpected natural cause of death

Deaths in this category are when a loved one passes away unexpectedly but from natural causes. This could be as a result of contracting an infection or respiratory illness or infectious diseases. It can also include illness such as cancer.

Unexpected unnatural cause of death

If the death of a loved one is placed into this category, the cause is linked to reasons where the individual may have decided to take their own life and their death was intentional. Examples include hanging, drug toxicity, drowning, a fall and injuries from an external cause.

Unable to obtain cause

In an unfortunate number of small cases, it is very difficult from the information available or shared with us to determine the actual cause of death, even after in depth screening is done. We will always try to identify a cause of death to categorise the deaths so we can learn from any deaths to help improve the outcomes and experiences for our service users, families and carers.