Freedom of Information Request – Ref: FOI 386-2025
Thank you for your recent Freedom of Information request. Please find our response below.
You asked:
I am writing to request information under the Freedom of Information Act 2000 regarding your compliance with the Learning from Deaths Guidance issued by NHS England (2017) which ensures your trust complies with the National Health Service (Quality Accounts) (Amendment) Regulations 2017.
This requires every NHS Trust to annually report (with a quarterly breakdown) the number of patients who died during the reporting period, how many case record reviews or investigations took place, and estimate how many deaths were determined to be likely due to problems in the care provided. It also requires the reporting of a summary of lessons learnt, what actions have been taken as a result, and what the impact of these actions has been.
Included in the Quality Accounts should also be the number of case record reviews and investigations relating to deaths in the previous reporting period that were only concluded in the most recent period and an estimation of how many of those deaths were due to problems in the care provided.
Please provide answers to the following questions for the most recent reporting period (2023/24):
1. Policy and Governance
a. Does your trust currently comply with the requirements of the Leaming from Deaths Guidance?
Our response:
Yes
You asked:
b. If not do you have plans to comply with it and if so by when?
Our response:
Not applicable
You asked:
2. Reporting
a. How many deaths were reported within your trust during the reporting period (2023/24)?
Our response:
693
You asked:
b. How many of these deaths were reviewed, and how many were judged more likely than not to have been avoidable?
Our response:
61 cases were reviewed.
Our review tool does not categorise deaths as avoidable or not.
You asked:
c. Have you published quarterly reports on learning from deaths on your website, as required by the guidance? Please provide links to the most recent reports.
Our response:
Yes, please see the link below:
You asked:
d. Is information on learning from deaths included in your latest Quality Account?
Our response:
Yes
You asked:
3. Family Involvement
a. Are families and carers involved in the review process where appropriate?
Our response:
Yes
You asked:
b. Please provide the number of deaths that were reviewed in this period (2023/24) where families and carers were involved and engaged in the review.
Our response:
17
You asked:
4. Actions and Learning
a. Please provide a summary of all actions taken as a result of the learning from deaths process in the last reporting period.
Our response:
The Trust has identified the following learning points in relation to deaths reported in 2023-2024:
Mental Health & Learning Disability Services
- New employees at Charlton Lane Hospital should attend End of Life Masterclass training to ensure that they are aware of how to access End of Life resources. This is now included in local induction and details of how to access information relating to the syringe driver, the Rapid Response Team and contact details for the Trust’s End of Life Lead.
- Where a patient on a community team caseload has a range of significant physical health services comorbidities, the Complex Care at Home Team can provide support on referral for those with one of more of the following: complex long-term conditions, medication management issues including polypharmacy, dementia diagnosis or suspected resulting in worsening physical health conditions, loneliness, bereavement, health related anxiety affecting their ability to self-manage their health and regular hospital admission or at risk of inappropriate unnecessary hospital admission.
- Patients with advanced dementia are at increased risk of falling.
- The multidisciplinary clinical team can consider that transfer to the Emergency Department of a patient for head injury is not in an incapacitious patient’s best interests, including in severe frailty or palliative care. This will be a best interests decision made by the multidisciplinary team in consultation with the patient’s family.
- Staff must be familiar with the Falls Policy, in particular managing patients with a head injury in line with NICE guidance.
- Antipsychotics (particularly clozapine) have been associated with an increased incidence of pneumonia. Pneumonia is reported as a rare side effect with clozapine (1/1000 to 1/10,000 patients). Pneumonia is associated with inflammation which can potentially increase plasma clozapine levels. An increase in clozapine levels may give rise to an increase in side effects. Aspiration pneumonia can also occur because of hypersalivation with clozapine.
- Mental Capacity Act (MCA) assessments (MCA 2005 section 2 and section 3) should be clearly documented. The Best Interests checklist (MCA 2005 section 4) should be considered for best interest’s decisions.
- If informed of the death of a community patient by a 3rd party, await verification of death via the ‘status’ on RIO (Records system for mental health and learning disability services) before removing a patient from a caseload. A black circle on RIO indicates that the death has been informally recorded either by the Health Records Team or the National Spine, but a death certificate has not been processed. A black diamond on Rio indicates that the death has been formally confirmed by receipt of a death certificate.
Community Hospitals
- Take timely advice from palliative care if refractory symptoms, including constipation, delirium are present.
- Help the helpers – support staff supporting patients with potentially traumatic events.
- To reduce the risk of medication errors, staff must be aware of human factors and ward pressures.
- Read & check prescription charts. Verbalize thought processes while preparing the drug. “This is…”. Do not assume the other understands the rational as to why it is being given.
- Palliative Care Service can be contacted 24/ 7 for advice and support if symptom relief is difficult to manage.
- Verbal orders for medication can now be taken over the phone, as per POPAM section 2.1.11 (local Trust Policy) and this guidance has been shared with medical staff.
- Staff must ensure that they are acting lawfully and be familiar with the Mental Capacity Act, Code of Practice, and Standard Operating Procedure for Deprivation of Liberty Safeguards. All documentation must be thoroughly completed.
- MCA assessments (MCA 2005 section 2 and section 3) should be clearly documented. The Best Interests checklist (MCA 2005 section 4) should be considered for best interest decisions.
- Each team should appoint a colleague to become an MCA Champion and staff should be able to improve their knowledge of MCA by attending the weekly online drop-in sessions and discussing cases.
- Ensure monitoring of patients’ bowels regularly and review on a daily ward round ensuring patients are prescribed appropriate laxatives. These can be administered covertly if Best Interest guidance is appropriately followed and documented.
- For patients with identified faecal loading plan, prescribe and administer a suitable bowel management regime.
- Be mindful that if patients with cancer are having abdominal symptoms it is important to check calcium levels as they could be suffering from bone metastases causing hypercalcemia.
- Ensure there are several family members contact numbers on the shared care and electronic patient record. Check awareness that the Next of Kin (NOK) is fully understanding the conversations from the teams. Be aware of the potential need to include the other family members as a support for the NOK and be mindful of the post death bereavement process and who will be supporting the NOK.
Next steps:
Should you have any queries in relation to our response, please do not hesitate to contact us. If you are unhappy with the response you have received in relation to your request and wish to ask us to review our response, you should write to:
Louise Moss
Head of Legal Services / Associate Director of Corporate Governance
c/o Gloucestershire Health and Care NHS Foundation Trust
Edward Jenner Court
1010 Pioneer Avenue
Gloucester Business Park
Brockworth, GL3 4AW
E-mail: louise.moss@ghc.nhs.uk
If you are not content with the outcome of any review, you may apply directly to the Information Commissioner’s Office (ICO) for further advice/guidance. Generally, the ICO will not consider your case unless you have exhausted your enquiries with the Trust which should include considering the use of the Trust’s formal complaints procedure. The ICO can be contacted at: The Information Commissioner’s Office, Wycliffe House, Water Lane, Wilmslow, Cheshire SK9 5AF.