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Deaths caused by care in 2021/22

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Dear Sir/Madam,

With reference to the following reporting guidelines set out by NHS Improvement (see page 15, prescribed information 27.1 to 27.5, link here: https://www.england.nhs.uk/wp-content/up...)

 
1) Please tell me in the reporting period 2021/22 the number of deaths that occurred at your Trust for which a case record review or investigation has been carried out which the provider judges as a result of the review or investigation were more likely than not to have been due to problems in the care provided to the patient, with an explanation of the methods used to assess this.
 

NOTE: By 'more likely than not' caused by care, I mean given a score of 3 (probably avoidable), 2 (strong evidence of avoidability) or 1 (definitely avoidable) on the inpatient structured judgement reviews (SJR), as assessed using the Royal College of Physicians avoidability of death criteria. If you do not use this system, please ignore this note.

2) Please provide me with a brief overview of the FIRST FIVE incidents in 2021/22 identified in question 3 (i.e. cases of deaths that were more likely than not caused by problems in care), withholding any identifying information that would run into a Section 40 exemption.
 
3) Finally, can you please summarise what the Trust learnt and what actions have been taken as a result of the aforementioned cases/investigations.

Yours faithfully,

Mark Tovey

FOI, Rf (ROYAL FREE LONDON NHS FOUNDATION TRUST), Royal Free London NHS Foundation Trust

Dear Mark Tovey

Thank you for your request under the Freedom of Information Act.  The
reference for this request is noted in the subject header above.

You will receive a response from us within 20 working days of receipt or
an explanation as to why this is not possible. 

Yours sincerely

Freedom of Information Team
Royal Free London NHS Foundation Trust

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FOI, Rf (ROYAL FREE LONDON NHS FOUNDATION TRUST), Royal Free London NHS Foundation Trust

8 Attachments

  [1]http://freenet/docs/Comms/Toolkit/020%20...

Royal Free London Group Headquarters

Anne Bryans House

77 Fleet Road

London NW3 2QH

                                                                                                                                                                                                                                            
                               
                                                                                                                                                                                                                                                                                         

 

Dear Mark Tovey

 

Thank you for submitting a request for information under the Freedom of
Information Act 2000.  Please find the response below.  This response
covers the hospitals and services managed by the Royal Free London NHS
Foundation Trust, namely the Royal Free Hospital, Barnet Hospital and
Chase Farm Hospital and associated group services.  

 

The response

 

 1. Please tell me in the reporting period 2021/22 the number of deaths
that occurred at your Trust for which a case record review or
investigation has been carried out which the provider judges as a
result of the review or investigation were more likely than not to
have been due to problems in the care provided to the patient, with an
explanation of the methods used to assess this.

 

NOTE: By 'more likely than not' caused by care, I mean given a score of 3
(probably avoidable), 2 (strong evidence of avoidability) or 1 (definitely
avoidable) on the inpatient structured judgement reviews (SJR), as
assessed using the Royal College of Physicians avoidability of death
criteria. If you do not use this system, please ignore this note.

 

8 deaths. Regarding the methods used, the trust has a Learning from Deaths
Policy, which is attached. Please note that some names of individuals have
been redacted from the document as this information constitutes personal
data and is therefore exempt under Freedom of Information Act 2000 Section
40(2) (Personal Information). 

               

 2. Please provide me with a brief overview of the FIRST FIVE incidents in
2021/22 identified in question 3 (i.e. cases of deaths that were more
likely than not caused by problems in care), withholding any
identifying information that would run into a Section 40 exemption.

Please see categories of incidents below:

 

• Maternity guidelines – procedure/protocol not followed
• Intrauterine death/still birth > 24 weeks
• VTE during hospitalisation
• Patient accident
• Medication prescribing

 

 3. Finally, can you please summarise what the Trust learnt and what
actions have been taken as a result of the aforementioned
cases/investigations.

Royal Free London NHS Foundation Trust does not hold this information.
Some cases are still undergoing review and learning is not easily
extractable from ongoing records. The trust can provide the attached
Quality Accounts report, which contains some of the learning published
(page 50).

 

 

Your appeal rights

 

I hope that this response deals with your enquiry to your satisfaction,
however if not you have two options:

 

·         If you do not feel that we have provided you with the
information you requested, you may contact us again and state what
information you still require.  However if you ask for additional and/or
different information this will be dealt with as a new request.

 

·         All applicants have the right of appeal and can request an
internal review.  The internal review must be focused on the original
request and should identify how the trust’s response failed to answer your
information request and explain what you would like us to review.  Appeals
should be made in writing, within 40 working days of the date of the
response, and addressed to Mr Kevin Winter, Associate Director of
Information Governance, Royal Free London NHS Foundation Trust at
[2][email address] .

 

If you are not satisfied with the internal review, you can appeal to the
Information Commissioner.  The contact details are: Information
Commissioner's Office, Wycliffe House, Water Lane, Wilmslow, Cheshire, SK9
5AF, telephone 01625 545 700 or see [3]www.ico.org.uk

 

Open Government Licence

 

The trust allows you to reuse this information under the Open Government
Licence found at the following [4]link. 

 

Yours sincerely

 

Freedom of Information Team

Royal Free London NHS Foundation Trust
Anne Bryans House

77 Fleet Road, London, NW3 2QH

 

[5]www.royalfree.nhs.uk
We’re on Instagram, [6]follow us!

 

[7]twitter[8]facebook[9]linkedin

[10]values sig

 

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We don't know whether the most recent response to this request contains information or not – if you are Mark Tovey please sign in and let everyone know.