Learning from deaths: Using the structured judgement review (SJR) methodology

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Background & Problems

GHNHSFT introduced a policy for reviewing deaths in 2017 based on the SJR methodology which identified triggers for which deaths to review. To support implementation the Datix system was modified to report deaths. The new tool required a culture change in how mortality was reviewed and raised concerns regarding responsibilities, workload and resource which needed to be overcome.

Aims

1. To increase SJRs undertaken by 50%.
2. To improve numbers of key messages reported by 50%.
3. To produce mortality reports.

Method

Based on the numbers of SJRs undertaken 4 specialties were identified. A review was carried out as to what data the specialties’ leads and the HMG wanted available on mortality and what data the Datix system could produce. Datix was amended to produce the required statistics and a key learning message box was added to focus learning.

Results

The project exceeded its aims by increasing SJRs undertaken by 81% and the number of key learning messages by 150%. Influencing factors were the work of the Hospital Mortality Group members raising the profile of SJRs and the Registrar review project from September 2018. In the 6 months of the project 4 specialty reports, 2 divisional presentations and one expert group report were completed with positive feedback received.

Implications

The success of the project was influenced by key clinicians who engaged with the tool and responded positively to being given data with which to identify learning and make improvements. The next steps are:

1. Continue to improve engagement by extending reports to other specialties and expert groups
2. Improve timeliness of SJR completion and quality assure process
3. Circulation of key learning via newsletters, posters etc
4. Improve multidisciplinary involvement in SJRs.
5. Clarify links between SJRs and duty of candour/serious incidents.