Welsh Government
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Analysing all patient deaths to improve standards of care in Wales

A senior doctor will lead work to make sure the way the NHS reviews the records of all patients who die in hospital is consistent throughout Wales, Health Minister Mark Drakeford announced today. 

In July, the Welsh Government published an independent review into hospital mortality data. It concluded the current risk adjusted mortality index (RAMI) measure is not an effective “smoke alarm” to warn about potential failings in care at a hospital.

The Palmer review said the two-stage process of reviewing the medical notes of all patients who have died in hospital – a system pioneered in Wales – could provide a better, more robust way of assessing safety and quality of care.  

The Health Minister has announced consultant pathologist Dr Jason Shannon will look at how variations in this process can be reduced so a consistent approach is taken across the country.

Dr Shannon, assistant medical director at Cwm Taf University Health Board, will lead the further development of the Wales-wide approach to mortality reviews and extending them to deaths which occur in the community.  

He will also examine whether independent medical examiners, who will be introduced in Wales and England under changes brought in by the Coroners and Justice Act, could be responsible for the first stage of the case note mortality review process in Wales.

Professor Drakeford said:

“The evidence from mortality case reviews demonstrates very clearly that deaths in Welsh hospitals are overwhelmingly not avoidable. Each one is a matter of intense sorrow and distress to those individuals most closely involved, including those who have provided care to the person who has died.

“It is from these reviews that health boards learn how the overall quality of care can be improved. While mortality case note reviews already provide the most reliable and informative means of analysing deaths in hospitals there is more that can be done to improve the process further.

“I am pleased to announce Dr Shannon will lead this work to develop the Wales-wide approach to mortality reviews and extending them to deaths which occur in the community.”

Consultant Pathologist and Assistant Medical Director at Cwm Taf University Health Board Dr Jason Shannon said:

"In Cwm Taf, we do not rely solely on mortality indices to tell us about patient safety, we are pioneering the process of examining in detail the clinical record and circumstances in which a patient dies in hospital - the case note mortality review.

"From April 2013, the hospital notes of every patient dying in either Prince Charles or Royal Glamorgan Hospital have been or are in the process of being reviewed by a team of senior clinical staff including GPs, hospital specialists and senior nursing staff. As of April 2014 we extended this process to other hospital sites across Cwm Taf.

“Our aim is not just to prevent avoidable death but to prevent any harm to patients, especially that which results in long-term suffering or disability. The process has already been valuable in highlighting areas where we think we could do better. For example, we have put in place more effective measures to reduce the risk of patients developing blood clots and significant infection during hospital admission.

"I am delighted to be taking up the role on behalf of Welsh Government to work with other health boards to expand this work across the Welsh NHS

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