The Christie NHS FT Annual Report & Accounts 2019-20

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

malignancy. A third incident related to management of a gastrostomy on the ward. None of these incidents contributed to the patients’ deaths.

Five mortality reviews were triggered by concerns raised by bereaved relatives, and all were managed by PALS. • One family had a concern about provision to stay with a dying patient. The mortality review identified no lapse in care. This admission was only a few hours in duration and nursing staff had not been made aware of any concern at the time. • Another family raised a concern around lack of an available side room for their dying relative. The mortality review found that nursing staff made alternative reasonable arrangements to manage the situation. • Another family raised a concern around a delay in transferring a patient from another hospital to the Christie. The mortality review found that Christie team were regularly communicating with team caring for patient at other trust. Management was appropriate across both trusts and no lapse in care was identified. Time to transfer was 5 days due to bed capacity and did not impact on outcome. • Families raised concerns around care at end of life on 2 occasions. The mortality reviews found comprehensive input from the supportive care team and consultant led oncology management during the final admissions for both, with frequent discussion with the patients and families, and expectations managed sensitively. End of life care and overall care were rated as excellent or good in both cases. Learning from deaths Areas for improvement identified through mortality reviews 2019/20 are listed below. A themed analysis of reviewers’ comments is produced, where reviewers indicate an opportunity for improvement, even if overall care was rated good. This is undertaken every 6 months and presented to the Quality Assurance Committee. These include: Confusion over responsible consultant post admission Lack of clear documentation of consultant reviews and board rounds (pre electronic noting) Fluid balance monitoring and documentation Gaps in senior review over a weekend (although care was appropriate with no adverse outcome Clear handover between clinical teams in respect of patients on intensive chemotherapy regimen

Peri-procedural care (drains and gastrostomy) with poor communication Delay in escalation of a deteriorating patient (no impact on outcome)

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