The Christie NHS FT Annual Report & Accounts 2019-20

The Christie NHS Foundation Trust Annual Report & Accounts 2019-20

Table 4: Quarter 1 - 4 Ratings of overall care* after Mortality Group meeting 28.01.2020: *RCP rating 1=very poor care, 2=poor care, 3=adequate care, 4=good care, 5=excellent care 2019 Month Total deaths Total Deaths Reviewed RCP 1 RCP 2 RCP 3 RCP 4 RCP 5 Apr 29 12 - - 1 6 5 May 28 6 - - 2 2 2 Jun 18 6 - - 1 1 4 Jul 18 3 - - - 2 1 Aug 22 10 - - 2 5 3 Sep 24 12 - - 2 4 6 Oct 34 10 - 1 1 4 4 Nov 15 4 - - - 1 3 Dec 26 6 - - 1 - 5 Jan 19 5 - - 1 4 - Feb 33 2 - - - 1 1 Mar 19 0 - - - - - Total 286 76 - 1 11 30 34 This data reflects the final ratings in completed reviews as ratified at MSG for avoidability and overall care as of 4 th March 2020. There has been one death of a patient with a learning disability in 2019/2020. This has been reported to LeDeR for further scrutiny; the mortality review did not find any concerns. One death was considered to have a >50% chance of avoidability (score 3). Issues were identified around delays in escalation and recognising cardiac complications in a deteriorating patient. A further root cause analysis investigation was conducted, and learning was shared with clinical teams at the Divisional Governance day (January 2020). Overall care was rated as 2 (poor) in one review. Several issues were identified and these were investigated further through the second stage executive review process. These were around inappropriate internal transfer to the procedures unit, and post procedural care on the ward. These did not directly lead to the death of the patient but areas for improvement were identified.

No deaths required to be reported to CQC and the Trust has not received any mortality outlier notification.

Three mortality reviews were triggered by a clinical incident that was investigated through the trust governance process. One incident related to the management of diabetes prior to a patient undergoing an intervention on the procedure unit. Another related to a delay identifying high methotrexate levels in a patient receiving in-patient high-dose methotrexate for advanced

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