Quality report 2021-2022

No deaths were considered to have a >50% chance of avoidability (score 1-3).

There were no cases with an overall care score of very poor (score 1) or poor (score 2)

No deaths required to be reported to CQC and the Trust has not received any mortality outlier notification. Of the 15 cases reviewed for deaths in the previous reporting year, all 15 were considered definitely unavoidable (score 6) and rater good or excellent for overall care (score 4 or 5). Six mortality reviews were triggered by concerns raised by bereaved relatives, and all were managed by PALS. One related to a patient fall that was investigated through the usual incident investigation process which found the fall to have been unavoidable and did not contribute to the patient’s death. In two cases the concerns related to the Covid-19 visitor restrictions that were resolved after a meeting between the clinical teams and the families. Three cases related to concerns raised around provision of end of life care. The mortality reviews for these patients included input from the supportive care team and no significant lapses in care were identified. Covid Related Deaths There have been 52 Covid-related in-patient deaths in total at The Christie to date, 23 of which occurred in this reporting period. Of the 23 Covid-related in-patient deaths in 2021/22, 14 patients died of Covid (Covid on part 1a-c of death certificate), and 9 patients died with but not directly of Covid (Covid on part 2 of death certificate). There were no patients with a Covid-related death during this reporting period who tested positive 15 days or more after admission (meeting the NHSE definition for definite hospital acquired disease). Learning from deaths Aspects of good practice and areas for improvement are fed back to the appropriate clinician. Any concerns identified are also shared within directorates or more widely, especially if associated with an incident or complaint. Examples of learning from mortality reviews during this reporting period include: • An issue where ceiling of care decisions on electronic Allow a Natural Death forms could expire without notifying the clinical team. This was rectified with support from Digital and the resuscitation committee. • A Head Injury triage tool has been introduced to the Christie Hotline following a mortality review that identified a patient was admitted to the Christie following a traumatic head injury which should have been diverted to a trauma centre. The head injury did not contribute to the patients death • Multiple examples of excellent end of life care with ward and supportive care teams managing challenging circumstances related to COVID-19 visitor restrictions sensitively and compassionately.

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