Death Certification And Mortality Review Policy
Death Certification and Mortality Review PolicyDate Issued:Review Date:Document Type:ContentsParagraph123456789AppendicesAppendix AAppendix BAppendix CAppendix DAppendix EAppendix FAppendix GAppendix HAppendix IVersion:5.029 September 201729 September 2018PolicyExecutive SummaryDeath Certification FlowchartInternal Mortality Review FlowchartScope and PurposeDefinitionsDetails of Procedure to be followedRoles and ResponsibilitiesRelated Trust PoliciesCommunication PlanProcess for Monitoring Compliance/Effectiveness of thisPolicyArrangements for Review of this PolicyReferencesGuidance on the completion of the medical certificate ofcause of deathBlank specimen of medical certificate of cause of deathReporting death to HM CoronerInternal Medical Examiner Group Terms of ReferenceTrust Mortality Review Group Terms of ReferenceMaternal DeathsMorbidity & Mortality Meeting StandardsChild Death & Deterioration Group Terms of ReferenceLearning Disabilities Mortality Review Pro t StatusThis is a controlled document. Whilst this document may be printed, the electronic versionposted on the intranet is the controlled copy. Any printed copies of this document are notcontrolled.As a controlled document, this document should not be saved onto local or network drives butshould always be accessed from the intranet.Page 1 of 34
Executive SummaryThe purpose of this policy and the associated guidelines is to help improve the quality of theTrust’s mortality data by supporting doctors in the completion of Medical Certificates ofCause of Death (MCCDs), determining when a death should be reported to HM Coroner andidentifying and investigating (through a variety of means) deaths that might have avoidablefeatures or where an adverse event occurred prior to death. It describes the role of theInternal Medical Examiner Group (IMEG) in the process of post-death scrutiny.Information about the completion of certificates for stillbirths or children dying under the ageof 28 days is not specifically included within this document. The review processes describedrelate to deaths of patients over the age of 18 years, with the exception of Appendix H whichdescribes the Child Death and Deterioration Group terms of reference.Flowcharts showing the review processes are provided overleaf.Page 2 of 34
DEATH CERTIFICATION REVIEW PROCESSDeath due to natural causesCoroner’s ProcessInternal ReviewReferral by Registration ServiceInquestReferralto HMCDeath on WardIMEG AApproved MCCDBereavement MeetingConcerns RaisedInternal Review / Investigation(see next flowchart)Page 3 of 34
INTERNAL MORTALITY REVIEW PROCESSSpecialityM&M(with directedquestions)ScopingMeetingNo adverseevent butpotentiallearningIMEG REVIEWPotential seriousadverse event /avoidable deathCare appearsto be belowexpectationsAvoidability Rating 1, 2, or 3Action: Root Cause Analysis andaction planAvoidabilityRatingAvoidability Rating 4, 5, or 6Action: No Further Action1.2.3.4.5.6.No CareConcernsAvoidability RatingDefinitely avoidableStrong evidence of avoidabilityProbably avoidable (more than 50:50)Possibly avoidable, but not likely ( 50:50)Slight evidence of avoidabilityDefinitely not avoidablePage 4 of 34No FurtherActionTMRG(structured casenote review)AvoidabilityRating
1Scope and PurposeThis policy relates to all UHS in-patient deaths.The objectives are: To ensure that the medical information recorded on MCCDs accurately reflectsthe cause of death including where a patient has a hospital acquired infectionthat has contributed to their death To ensure that certificates are completed in a timely manner and comply with thestandards set out in this document To ensure that where required, deaths are reported appropriately to HM Coroner To improve the overall quality of completed certificates To identify areas of concern that require further investigation and to co-ordinateand disseminate learning To improve the experience of bereaved relatives2DefinitionsAER – Adverse Event ReportCDAD – Child Death and Deterioration GroupIMEG – Internal Medical Examiner GroupM&M – Morbidity & Mortality Review GroupsMCCD – Medical Certificate of Cause of DeathQGSG – Quality Governance Steering GroupSIRI – Serious Incident Requiring InvestigationSISG – Significant Incident Scrutiny GroupTMRG – Trust Mortality Review Group3Details of procedure to be followed3.1Attendance at IMEG Attendance at the IMEG panel is mandatory, but this must not delay the issuingof the medical certificate of cause of death. Attendance is therefore required nolater than the day following the death of a patient, or Monday for a death at theweekend. The doctor attending the IMEG panel will ensure that they have discussed thepatient’s care with their Consultant, or in his/her absence their Registrar, to makesure that they are familiar with the patient’s case, have agreed a draft cause ofdeath and identified any areas of concern or complaints raised by the patient’sfamily. The doctor attending the IMEG panel will bring the patient’s medical records withthem to the meeting. The IMEG panel will meet twice-daily (Monday to Friday), between 9:00am and10:00am, and between 2:00pm and 3:30pm (4:00pm on Mondays). Appointment slots between 9:30am and 10:00am will be reserved for the reviewof deaths at Countess Mountbatten House via video link Appointments will be made via the Bereavement Care office (ext 4587). Where a medical certificate of cause of death is issued outside normal workinghours, for religious/cultural reasons (see 4.2), the issuing doctor will be requiredto attend the IMEG panel on the next working day for a retrospective review ofthe case.Page 5 of 34
3.2Issuing a Medical Certificate of Cause of Death outside normal working hoursfor religious or cultural reasons There will be occasions where, for religious or cultural reasons, there is arequirement for the rapid issuing of the death certificate and release of the bodyto facilitate burial within 24 hours. Where this is necessary, the followingprocedures should be followed. The medical certificate of cause of death must be issued by a Consultant orRegistrar who has seen the patient prior to death. Where there is no Consultantor Registrar on duty who has treated the patient, a junior doctor who has beeninvolved in the patient’s treatment may issue the medical certificate of cause ofdeath, but only after discussing the case and agreeing the cause of death withthe responsible duty Consultant. Where there is no doctor on duty who has been involved in the patient’s care, thepatient’s named Consultant should be contacted and asked to deal with thecertificate. Except in cases where the death was expected, contact should be made with theCoroner to ensure that there is no reason for him to investigate the death further.If the Coroner is unavailable, then the death should be discussed with one of hisassistants. A medical certificate of cause of death book is held in the Hospital Control Roomfor these cases. In all circumstances, the doctor must present the case for a retrospective reviewby the IMEG panel on the next working day.3.3IMEG outcomes Potential AERs unrelated to the cause of death and which have not led to seriousharm (or have the potential to do so) will be reported on the UHS incidentreporting system and investigated via divisional governance and the patientsafety team. Falls, pressure ulcers and venous thromboemboli will be reported to the relevantsafety panels. Potential AERs that may have led to serious harm or contributed to the cause ofdeath will be reported to the patient safety team for serious adverse event casereview (scoping meeting) under the oversight of SISG and the AMD for safety. Cases where there are potentially avoidable features within the patient’s care,which may not necessarily constitute clear evidence of an AER should bereferred to the Trust Mortality Review Group (TMRG) for further in-depth analysisof avoidability and assessment of relevant learning for the clinical team andhospital trust. Cases with questions over elements of clinical care where there is potential foruseful learning for the responsible clinical team should be referred for discussionof directed questions at the relevant Morbidity and Mortality (M&M) meeting. The patient support services team should be informed of cases with known familyconcerns and should be made aware of deaths involving potentially seriousadverse events. Evidence of serious failures in care with implications for the safety of currentpatients will be escalated via the Associate Medical Director for Safety and theDeputy Director of Nursing and Quality, to the joint chairs of QGSG and thechairs of the Trust Executive Committee and Trust Board as appropriate.Page 6 of 34
3.4Adverse Event / Incident Reporting Where a death ‘may be related to a medical procedure or treatment whetherinvasive or not’ or ‘where the death was sudden and unexpected’, contactshould be made with the Trust’s Patient Safety Department by completing andsending an Adverse Event Form as per the Trusts Incident Reporting Policy.3.5Complaints Handling / Reporting Where relatives express concerns, or complain about care, an early resolutionmeeting should be offered with the patient’s Consultant and/or a senior memberof the nursing team. Advice can be sought from the IMEG panel and inexceptional cases, a meeting may be offered to relatives by the AssociateMedical Director for Safety or the Deputy Director of Nursing and Quality. Where an early resolution meeting is felt to be inappropriate, where an earlyresolution meeting fails to meet the needs of relatives, or where relatives wish fora more formal approach to their complaint, they should be referred to the Trust’sPatient Support Services. Further information can be found in the Trust’sConcerns and Complaints Policy.3.6Review of deaths in the community within 30 days of discharge from UHS Deaths within 30 days of discharge from UHS will be reported to IMEG, either bythe primary care provider or the Coroner’s office, either by telephone or by emailto the IMEG administrator or the bereavement care team. The informationprovided, together with information from the patient’s discharge summary andelectronic patient record will be reviewed by the associate medical director forsafety and a member of the bereavement care team. Deaths will be graded andreferred to other Trust processes in the same manner as inpatient deaths.Where appropriate, specific concerns or questions will be addressed to theprimary care provider for clarification, reassurance or investigation. Currently it is not possible to ensure all deaths in the community within 30 days ofdischarge will be identified, however processes will undergo further developmentto establish the highest possible level of reporting.4Roles and ResponsibilitiesChief Executive OfficerAs accountable officer, the Chief Executive is responsible for the overall leadershipand management of the Trust and its performance in terms of service provision,financial and corporate viability, ensuring that the Trust meets all its quality andsafety, statutory and service obligations and for working closely with other partnerorganisations. The CEO delegates aspects of this responsibility to relevant ExecutiveDirectors according to their organisational portfolios. The CEO directly managescommunications, information services and corporate affairs.Medical DirectorThe Medical Director has delegated authority and responsibility within the Trust formedical staff – including clinical practices and outcomes; professional regulation andclinical standards; clinical effectiveness; research and development and relationshipswith general practitioners.Executive Director of Nursing and Organisational Development (OD)The Director of Nursing and OD has delegated authority and responsibility for allaspects of infection prevention and control; nursing clinical practices and outcomes;professional regulation and clinical standards; training and development; governancePage 7 of 34
(including compliance, risk management, patient safety and experience); humanresources and workforce.Associate Medical Director for SafetyThe Associate Medical Director for Safety has delegated authority from the MedicalDirector for matters of safety and governance. The Associate Medical Director forSafety will be responsible for appointing senior doctors to deputise for him as theIMEG clinical lead.IMEG Clinical LeadWill either be the Associate Medical Director for Safety or his deputy. The IMEGClinical Lead will provide scrutiny of clinical events, ensure that the cause of deathhas been discussed with the senior clinician responsible for the deceased’s care andadvise if further investigation is required.Bereavement Care StaffA member of the bereavement care team will be in attendance at all IMEG meetingsto provide advice on the processes of; death certification, family liaison, post mortemexaminations and referral of deaths to HM Coroner.Patient’s Clinical TeamThe patient’s clinical team are responsible for attending the IMEG panel and issuingthe medical certificate of cause of death, or referring the death to HM Coroner, inaccordance with the standards set out in this document.5Related Trust Policies Bereavement Care Policy Incident Reporting Policy Incident Management Policy Concerns and Complaints Policy and Procedures Supporting Staff Involved in an Incident, Complaint or Claim Policy Post Mortem Consent & Human Tissue Disposal Policy Being Open: Duty of Candour Maternal Death Procedure6Communication Plan This document will appear in the ‘New and Updated’ area of Staffnet andcirculated to all M&M leads, TMRG and CDAD Training will be provided to IMEG reviewers and those undertaking mortalityreviews. Medical staff will receive 1:1 traing on completion of deathdocumentation at IMEG7Process for Monitoring Compliance/EffectivenessThe purpose of monitoring is to provide assurance that the agreed approach is beingfollowed – this ensures we get things right for patients, use resources well and protect ourreputation. Our monitoring will therefore be proportionate, achievable and deal with specificsthat can be assessed or measured.Key aspects of the procedural document that will be monitored:Page 8 of 34
What aspects ofcompliance withthe document willbe monitoredTimeliness of deathcertificationWhat will be reviewedto evidence thisThe time taken to attendIMEG / write the deathcertificateDeaths requiringNumber of deathsfurther internalescalated to M&M,review /TMRG or SISG.investigationThemed outcomes andavoidability ratings for alldeaths(1) State post not person.How and howoften will thisbe doneQuarterlyDetailsamplesize (ifapplicable)AllWho will coordinate andreport findings(1)BereavementCareWhich group orreport eavementCareQualityCommittee andTrust BoardWhere monitoring identifies deficiencies actions plans will be developed to address them.8Arrangements for Review of the PolicyThis policy will be reviewed one year from the date of approval.9References Births and Deaths Registration Act (1953) Guidance for Doctors certifying cause of death (Office of National Statistics, Sept2008) Healthcare Associated Infections and Death Certification (Chief Medical Officer,October 2007) Coroners and Justice Act (2009) Using the structured judgement review method: A guide for reviewers (RoyalCollege of Physicians 2016)Page 9 of 34
Appendix A: Guidance on completing the Medical Certificate of Cause of DeathYou are required to complete the Medical Certificate of Cause of Death, stating the cause ofdeath to the best of your knowledge and belief, if you attended the deceased duringhis/her last illness. You must not complete the certificate if you did not attend the deceasedduring his/her last illness, or if you do not know the cause of death. A blank specimencertificate can be found at Appendix B.When completing the certificate: Please ensure you write legibly Ensure that you complete the patient’s details correctly You must circle either:(1) The certified cause of death takes account of information obtained from post-mortem(2) Information from post-mortem may be available later(3) Post-mortem not being heldor (4) I have reported the death to the Coroner for further actionand(a) Seen after death by me(b) Seen after death by another medical practitioner but not by meor (c) Not seen by a medical practitioner Do not use medical symbols or abbreviations Print your full name clearly after your signature and add your medical qualification(s) andGMC registration number. (If qualifications were obtained in another country, pleasestate which university town it was obtained in and the year it was awarded) Give the name of the Consultant responsible for the care of the patientCompleting the Cause of Death Statement Part I- State the disease or condition directly leading to death on the first line [Part I (a)]- Complete the sequence of diseases of conditions leading to death on subsequent lines- State the Underlying Cause of Death on the last completed line of Part Io The disease or condition directly leading to the death and the Underlying Causeof Death may be the same. In this case you only need to complete the first line ofPart I -Part IIIf there is some significant condition or disease that contributed to the death but which isnot part of any sequence leading directly to death, you should record it in Part II, e.g.Diabetes Mellitus or Parkinson’s DiseaseExampleI (a) Disease or condition directly leading to death: Intracerebral Haemorrhage(b) Other disease or condition, if any, leading to I(a): Cerebral Metastases(c) Other disease or condition, if any, leading to I(b): Squamous Cell Carcinoma of the LeftMain BronchusII Other significant conditions CONTRIBUTING TO THE DEATH but not related to the diseaseor condition causing it: Type II DiabetesPage 10 of 34
Modes of dyingDo NOT state a ‘mode of dying’ unless you specify the disease or condition which precededit, otherwise the Registrar of Births and Deaths will report the death to the Coroner as ‘causeof death unknown’.Modes of dying include Organ Failure (e.g. Heart Failure, Renal Failure etc), Cardiac orRespiratory Arrest, Coma, Cachexia, Debility, Uraemia and Shock.The addition of Acute or Chronic to any of these terms does not make them acceptable as acause of death.More comprehensive guidance is given in the notes at the beginning of every MedicalCertificates of Cause of Death book.Other administrative tasksThe outcome of all IMEG discussions, including the cause of death or referral to HM Coronershould be recorded in the patient’s medical records.All co-morbidities, whilst not necessarily included on the Medical Certificate of Cause ofDeath, must be recorded on the patient’s e-discharge summary.Page 11 of 34
Appendix B: Blank specimen Medical Certificate of Cause of DeathPage 12 of 34
Appendix C: Reporting deaths to HM CoronerThe Coroner’s service works within a legal framework. It is the Coroner’s duty to investigatedeaths which are reported to him/her and which appear to be due to violence, or areunnatural, or are sudden and of unknown cause.Reportable deaths The cause of death is unknownIt cannot readily be certified as being due to natural causesThe deceased was not attended by a doctor during his/her last illness, or was not seenwithin the last 14 days or seen after deathThe death occurred during an operation or before full recovery from the effects of ananaesthetic or was related to the anaesthetic. (In any event, a death occurring withinone year of an operation/invasive procedure should be discussed with the Coroner’sOfficer)The death may be related to a medical procedure or treatment whether invasive or notThe death may be linked to an accident, whenever
Death Certification and Mortality Review Policy Version: 5.0 Date Issued: 29 September 2017 Review Date: 29 September 2018 Document Type: Policy Contents Page Paragraph Executive Summary 2 Death Certification Flowchart 3 Internal Mortality Review Flowchart 4 1 Scope and Purpose 5 2 Definitions 5 3 Details of Procedure to be followed 5
mortality, investing on maternal education targeting those at risk groups is recommended. Keywords: Under-five mortality, Infant mortality, Childhood mortality, Determinants of under-five mortality, Gamo Gofa, Ethiopia Background The right to life is declared to be a fundamental human right [1]. It is the obligation of nations and governments
LESSON 51 Mortality Management Table 51-1. Mortality rate for swine. Animal Type Mortality, % Newborn pigs 10 Nursery pigs 2-3 Sows 6 Boars 1 Finishing hogs 2 Table 51-2. Mortality rate for poultry. Average Mortality Rate Poultry Type During Flock Cycle, % Layer hen 14 pullet 5 Broiler breeder pullet 5 breeder hen 11 breeder male 22 roaster 8 .
A review of recent trends in mortality in England 7 . mortality than the number of deaths. Period life expectancy at birth is an alternative summary indicator of mortality. The overall age-standardised mortality rate in England has generally been declining (improving) in recent decades for both males and females. However, the rate of
Page 2/34 Introduction 1 Introduction Motivation Literature Review: Mortality Literature Review: Term Structure Models 2 Factor Analysis of Mortality Forecasts 3 Forward Mortality Factor Models 4 A Non-negative Model Variant 5 Application 6 Conclusion Daniel Bauer Coherent Modeling of the Risk in Mortality Projections
South Asia have the highest maternal mortality, contrib-uting up to 86% maternal mortality globally [1]. Tanzania is among the sub-Saharan countries with the highest maternal mortality. The maternal mortality ratio in Tanzania is as high as 556 maternal death in every 100,000 live births [2]. It has been reported that the most leading causes of
Mortality Review, Ohio Pregnancy Associated Mortality Review, and the Wisconsin Maternal Mortality Review Team. We would also like to acknowledge the University of Illinois at Chicago’s Center for Research on Women and Gender, Emory University Rollins School of Public
ers, infants, and young children. Maternal deaths account for 35 percent of mortality among women of reproductive age (PDHS 2007). In 2012, the maternal mortality ratio (MMR) was estimated at 996 per 100,000 births (Sathar, Wazir and Sadiq 2014); the infant mortality ratio (IMR) was 97 per 1,000 births; and the under-five mortality ratio
learning teams, guided inquiry activities, critical and analytical thinking, problem solving, reporting, metacognition, and individual responsibility. Strategies for the successful use of learning teams are discussed, the roles of the instructor in this learning environment are described, and implementation hints
