Landmark report shows hospitals learning from deaths to improve patient care

Published: 05 Oct 2018

A landmark new report published today by the Royal College of Physicians (RCP) reveals how hospitals are using a standardised review approach to learn from adult acute deaths and improve patient care. The publication of Learning from Deaths by the National Quality Board (NQB) in March 2017 mandated all English trusts to conduct mortality reviews, a move supported by the NMCRR programme.

The RCP’s National Mortality Case Record Review Programme (NMCRR), funded by NHS Improvement and the Scottish Government and commissioned by the Healthcare Quality Improvement Partnership, has developed the Structured Judgement Review (SJR) process to effectively review care received by patients who have died. SJR was developed to replace the variable local systems with a standardised, national, evidence-based method.

The NMCRR programme has been implemented in over 100 NHS trusts and health boards across England and Scotland since 2016.

The NMCRR programme team has trained around 480 healthcare professionals across England and Scotland, who in-turn have shared their training with at least 1500 other healthcare professionals including doctors and nurses.

The SJR tool enables understanding of the care delivered to adult patients before death in acute hospitals in a way that data from clinical coding and death certification cannot. SJRs maximise the potential for learning and improvement and encourage the development of quality improvement initiatives when problems in care are identified. Importantly the SJR also helps identify good practice for sharing within the NHS.

The report cites a number of case studies where the SJR has made positive contributions to improving healthcare for patients.

For example, Buckinghamshire Healthcare NHS Trust introduced medical examiners and the SJR process to screen all deaths in 2017. Within just six months 97 percent of deaths were screened and 12 per cent of all cases used the SJR process. This has resulted in:

  • informing improvements in end of life (EOL) care including promoting patient choice
  • encouraging formulation of personalised care plans in the hospital and the community
  • improved sepsis recognition and treatment
  • increased awareness of timely Do Not Attempt CPR (DNACPR) decisions and treatment escalation plans (TEP).

Dr Andrew Gibson Consultant Neurologist, clinical lead for the NMCRR said:

This pioneering NMCRR programme aims to implement a validated, standardised way of reviewing the case records of adults who died in hospitals across England and Scotland. The report demonstrates that through using a standardised review approach NHS trusts can successfully improve quality in patient care and safety. It also highlights the significant efforts required to implement the programme nationally and the enthusiasm from those involved to work collaboratively. 

Professor David Oliver, clinical vice president, Care Quality Improvement Department (CQID), and consultant in geriatrics and general internal medicine at the Royal Berkshire NHS Foundation Trust said:

Nearly half of deaths in the UK happen in hospital and quite rightly there has been growing political and professional focus in recent years on improving end-of-life care, support for the bereaved, and learning from and ultimately eliminating preventable deaths. It is therefore really positive to see that the use of our SJR validated, structured tool is already contributing to positive changes. So far we have trained 480 reviewers to use the SJR approach who are supporting hospitals to identify good practice and areas for improvement and develop stronger cultures of openness, learning and partnerships with families. There is still much to do, and our advice is that mortality reviews and other quality improvement initiatives should be fully embedded across all NHS Trusts.

The SJR process can also be used for a wide range of hospital-based safety and quality reviews, across services and specialities – not only for cases where people die in hospital. For example, it has been used to assess the care of people who have had a cardiac arrest in hospital; to review safety and quality of care before and during admission to intensive care and to review the care for people  who are admitted  at different times of the week.

To view the full report click here

Notes to editors

1 National Quality Board. National Guidance on Learning from Deaths: A Framework for NHS Trusts and NHS Foundation Trusts on Identifying, Reporting, Investigating and Learning from Deaths in Care. London: NQB, 2017.

For more information or to arrange an interview, please contact Joanna Morgan, communications manager, RCP Care Quality Improvement Department on 020 3075 1354.

The report will be available from 00.01 hours on Thursday 4 October 2018 on the RCP website:

The RCP can also be found on Twitter at: @RCPLondon


The Royal College of Physicians

The Royal College of Physicians (RCP) plays a leading role in the delivery of high‐quality patient care by setting standards of medical practice and promoting clinical excellence. The RCP provides physicians in over 30 medical specialties with education, training and support throughout their careers. As an independent charity representing over 35,000 fellows and members worldwide, the RCP advises and works with government, patients, allied healthcare professionals and the public to improve health and healthcare.

NMCRR Programme

The National Mortality Case Record Review (NMCRR) Programme contract was awarded to the Royal College of Physicians (RCP) in February 2016 and is funded by NHS Improvement and commissioned by the Healthcare Quality Improvement partnership (HQIP). The RCP collaborates with two partners to deliver the NMCRR Programme: the Yorkshire and Humber Improvement Academy (IA) in Bradford and Datix UK. The programme aims to develop and implement a standardised methodology for reviewing the case records of adults who have died in acute hospitals across England and Scotland. The programme also aims to improve understanding and learning about problems and processes in healthcare that are associated with mortality, and to share best practice.

The Healthcare Quality Improvement Partnership (HQIP)

The Healthcare Quality Improvement Partnership (HQIP) is led by a consortium of the Academy of Medical Royal Colleges, the Royal College of Nursing and National Voices. Its aim is to promote quality improvement in patient outcomes, and in particular, to increase the impact that clinical audit, outcome review programmes and registries have on healthcare quality in England and Wales. HQIP holds the contract to commission, manage and develop the National Clinical Audit and Patient Outcomes Programme (NCAPOP), comprising around 40 projects covering care provided to people with a wide range of medical, surgical and mental health conditions. The programme is funded by NHS England, the Welsh Government and, with some individual projects, other devolved administrations and crown dependencies.

Buckinghamshire Healthcare NHS Trust (BHT)

Buckinghamshire Healthcare NHS Trust provides a wide range of high quality acute and community services from two acute hospital sites in Stoke Mandeville and Wycombe, five community hospitals at Amersham, Buckingham, Chalfonts and Gerrards Cross, Marlow and Thame, and a number of community sites across the county, as well as in patients’ own homes. Around 6,000 staff serve residents across Buckinghamshire, Thame (Oxfordshire), Tring (Hertfordshire) and Leighton Buzzard (Bedfordshire) – a combined population of 500,000. It serves a much larger population, 1.5m, for burns and plastic services and 14m for spinal injuries.

Further details can be found at: