Flawed mortality reviews
Incorrectly completed or contradictory mortality reviews hindering adequate learning and preventing future deaths.
11 items
1 source
4 inquiries
Source spread
Where this theme appears
Flawed mortality reviews has been flagged across 1 independent accountability source:
11 inquiry recs
This theme has been identified in one data source. As more data is added, cross-references may emerge.
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Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (11)
R3 — Paediatric pathology in unexpected child deaths
Recommendation: We recommend that the provision of paediatric pathology services be reviewed with a view to ensuring that such services be engaged in every case in which the death of a child is unexpected or clinically unaccountable, whether the post mortem …
Unknown
F278 — Death certification
Recommendation: It should be a routine part of an independent medical examiners's role to seek out and consider any serious untoward incidents or adverse incident reports relating to the deceased, to ensure that all circumstances are taken into account whether or …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F277 — Death certification
Recommendation: National guidance should set out standard methodologies for approaching the certification of the cause of death to ensure, so far as possible, that similar approaches are universal.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F105 — Transparency use and sharing of information
Recommendation: Consideration should be given to whether information from incident reports involving deaths in hospital could enhance consideration of the hospital standardised mortality ratio.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
40 — Extend medical examiners to stillbirths
Recommendation: Given that the systematic review of deaths by medical examiners should be in place, as above, we recommend that this system be extended to stillbirths as well as neonatal deaths, thereby ensuring that appropriate recommendations are made to coroners concerning …
Gov response: 106. We accept these recommendations in principle. The medical examiners system has been trialled successfully in a number of areas across the country. We will soon be publishing a report from the interim National Medical …
Accepted
39 — Implement medical examiner system
Recommendation: There is no mechanism to scrutinise perinatal deaths or maternal deaths independently, to identify patient safety concerns and to provide early warning of adverse trends. This shortcoming has been clearly identified in relation to adult deaths by Dame Janet Smith …
Gov response: 106. We accept these recommendations in principle. The medical examiners system has been trialled successfully in a number of areas across the country. We will soon be publishing a report from the interim National Medical …
Accepted
38 — Improve perinatal mortality recording
Recommendation: Mortality recording of perinatal deaths is not sufficiently systematic, with failures to record properly at individual unit level and to account routinely for neonatal deaths of transferred babies by place of birth. This is of added significance when maternity units …
Gov response: 103. We accept this recommendation. We will explore the feasibility of publishing data about the safety and quality of maternity services at individual Trust level. 104. As recommended by the Morecambe Bay Report, MBRRACE-UK has …
Accepted
F279 — Death certification
Recommendation: So far as is practicable, the responsibility for certifying the cause of death should be undertaken and fulfilled by the consultant, or another senior and fully qualified clinician in charge of a patient's case or treatment.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F276 — Independent medical examiners
Recommendation: Sufficient numbers of independent medical examiners need to be appointed and resourced to ensure that they can give proper attention to the workload.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F275 — Independent medical examiners
Recommendation: It is of considerable importance that independent medical examiners are independent of the organisation whose patients' deaths are being scrutinised.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
LAMI-5 — National Agency to conduct or oversee and publish serious child case reviews
Recommendation: The National Agency for Children and Families should, at their discretion, conduct serious case reviews (Part 8 reviews) or oversee the process if they decide to delegate this task to other agencies following the death or serious deliberate injury to …
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