Freedom of Information request Mortality, Governance, Workforce and Service Variation

Freedom of Information Request – Ref: FOI 249-2026

Thank you for your recent Freedom of Information request. Please find our response below.

You asked:

Information for the reporting periods 2023/24, 2024/25 and 2025/26 (or the most recent data available for 2025/26).

1. Mortality and Learning from Deaths

1.1 Please provide the total number of deaths recorded among adult service users under the care of the Trust during each reporting period, including both community and inpatient services.

1.2 Please provide, where available, the number of those deaths recorded as resulting from natural causes or physical health conditions.

1.3 Please provide the number of Structured Judgement Reviews (SJRs), Learning from Deaths reviews, Serious Incident investigations, Patient Safety Incident Investigations (PSIIs), or equivalent mortality reviews completed during each reporting period.

Our response to questions 1.1, 1.2 and 1.3:

The information requested in questions 1.1 to 1.3 is available in the Trust’s published Quality Reports. Under section 21 of the Freedom of Information Act 2000, information that is reasonably accessible to the applicant by other means is exempt from disclosure. The relevant reports can be accessed through the Trust’s website: Gloucestershire Health & Care NHS Foundation Trust – With you, for you.

You asked:

1.4 Of the reviews identified above, please provide the number where deficiencies, omissions, delays or failures relating to physical health monitoring, physical healthcare provision, or management of physical health conditions were identified as a contributory factor.

Our response:

The Trust does not hold a centrally recorded total showing how many mortality reviews identified deficiencies, omissions, delays or failures in physical health monitoring, physical healthcare provision or the management of physical health conditions as a contributory factor. Mortality review findings are recorded narratively within individual reviews and reports. Identifying and counting all relevant cases would therefore require a manual review of those records.

As a trust we produce quarterly reports on the following data:

• number of deaths in their care
• number of deaths subject to case record review (desktop review of case notes using a structured method)
• number of deaths investigated under the Serious Incident framework (now PSII’s)
• number of deaths that were reviewed/investigated and as a result considered more likely than not to be due to problems in care
• themes and issues identified from review and investigation (including examples of good practice)
• actions taken in response, actions planned and an assessment of the impact of actions taken.

In order to meet the requirements above the trust holds 2 Mortality Review Groups (MRGs) each month:

• Physical Health Mortality Review Group
• Mental Health and Learning Disability Mortality Review Group

Within these meetings we have reflective conversations with teams whereby the discussion asks them to consider areas of good practice, areas of where something unexpected or something that surprised the clinical team occurred and where learning is identified by them for their area or wider trust.

In order to provide a degree of objectivity we do use the 2 rating scales Mazars and NCEPOD (click on document links below to access).  We use these to identify where there may be problems in care, MAZARS also identifies where natural or unnatural deaths may have occurred and may provide the figures the requestor is looking for? This data should be publicly available in the quality report or learning from deaths quarterly report.

Mazars Criteria

NCEPOD

You asked:

2. Service Performance and Governance

2.1 Please provide copies of any internal performance dashboards, quality reports, audits, benchmarking reports, Board papers, Quality Committee papers, Learning from Deaths reports, Physical Health Committee reports, or equivalent documents produced during the reporting period that compare physical health monitoring compliance rates, physical health outcomes, mortality rates, patient safety indicators, or other quality indicators between localities or teams.

2.2 Please provide copies of any reports, audits, reviews, investigations or action plans undertaken during the reporting period that identified significant variation in service performance, patient outcomes or quality indicators between localities or teams.

Our response to 2.1 and 2.2:

The Trust’s published Quality Reports and public Board papers contain relevant quality and performance information. Under section 21 of the Freedom of Information Act 2000, information contained in those publications is exempt from disclosure because it is reasonably accessible by other means. The clinical audit reports listed below are also provided in response to questions 2.1 and 2.2.

Trusts Quality Reports which are published on our website, please click on link; Gloucestershire Health & Care NHS Foundation Trust – With you, for you

Quality dashboard is also available to view on our website presented at Board (public session), please click on link; Gloucestershire Health & Care NHS Foundation Trust – With you, for you

2023-24 Clinical Audit Programme:

23-027 Audit of Physical Health Monitoring and De-brief post-Rapid Tranquilisation – Wotton Lawn Hospital – 23-027 Physical Health Monitoring post RT Final Report

23-139 Physical Health Monitoring for patients on Depot Antipsychotics – Gloucester Recovery Team – 23-139 Physical Health Monitoring Audit Final Report

23-143 Audit of Physical Health Monitoring and De-brief post-Rapid Tranquilisation – Wotton Lawn Hospital – 23-143 Physical Health Monitoring post RT Final Report

2024-25 Clinical Audit Programme:

24-013 Physical Health Examinations for Inpatients on Admission to Mental Health Inpatient Units – 24-013 Physical Health Examinations for Inpatients on Admission

24-016 Audit of Physical Health Monitoring and De-brief post-Rapid Tranquilisation – Wotton Lawn Hospital – 24-016 Physical Health Monitoring post RT Audit

2025-26 Clinical Audit Programme:

25-033 Physical Health Monitoring for patients on Depot Antipsychotics – Gloucester Recovery Team – 25-033 Physical Health Monitoring for patients on Depot Antipsychotic

25-093 Audit of Physical Health Monitoring and De-brief post-Rapid Tranquilisation – Wotton Lawn Hospital – 25-093 Physical Health Monitoring post RT Audit Report

25-094 Physical Health Examinations for Inpatients on Admission to Mental Health Inpatient Units – 25-094 PH Examination for Inpatients Audit Report

25-162 Audit of the Annual Physical Health Check for patients admitted to the Recovery Units – 25-162 Annual Physical Health Checks Audit Final Report

You asked:

3. Workforce and Resource Allocation – For each locality service and reporting period, please provide:

3.1 Approved staffing establishment (whole-time equivalent).

3.2 Actual staffing levels (whole-time equivalent).

3.3 Vacancy rates.

3.4 Vacancy rates specifically for Consultant Psychiatrists, Specialty Doctors, Mental Health Nurses, Physical Health Practitioners, and Care Coordinators.

Our response to questions 3.1, 3.2, 3.3 and 3.4:

You asked:

3.5 Copies of any locality-level workforce reports presented to senior management, Trust Board committees or quality governance meetings relating to staffing pressures, recruitment challenges or service delivery risks.

Our response:

The Trust has identified the documents listed in response to questions 2.1 and 2.2 as relevant to question 3.5. Following searches of the relevant records, the Trust does not hold any additional locality-level workforce reports within the scope of this request.

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.