Learning From Deaths Reporting 2023-24

Reference: 24-25529

Date response sent: 07/03/2025

Details of enquiry

1. Policy and Governance

a. Does your trust currently comply with the requirements of the Leaming from Deaths Guidance?

b. If not do you have plans to comply with it and if so by when?

2. Reporting

a. How many deaths were reported within your trust during the reporting period (2023/24)?

b. How many of these deaths were reviewed, and how many were judged more likely than not to have been avoidable?

c. Have you published quarterly reports on learning from deaths on your website, as required by the guidance? Please provide links to the most recent reports.

d. Is information on learning from deaths included in your latest Quality Account?

3. Family Involvement

a. Are families and carers involved in the review process where appropriate?

b. Please provide the number of deaths that were reviewed in this period (2023/24) where families and carers were involved and engaged in the review. •

4. Actions and Learning

a. Please provide a summary of all actions taken as a result of the learning from deaths process in the last reporting period.

Response sent

1. Policy and Governance

a. Does your trust currently comply with the requirements of the Leaming from Deaths Guidance?

No

b. If not do you have plans to comply with it and if so by when?

We do not hold this data.

Please note that the Freedom of Information Act (FOIA) applies to recorded information that exists at the time of the request. It does not require an authority to speculate nor provide opinions where this would involve the creation of new information, and this question could only be answered by creating new information.

Accordingly, if there are any particular documents, data or information that you would like to receive then the Trust would treat any reformulated request we receive as a fresh FOI request and consider it accordingly

2. Reporting

a. How many deaths were reported within your trust during the reporting period (2023/24)?

i. We have masked low numbers as the symbol ‘≤ 5’, which indicates where numbers are equal to 5 or less than 5.

It is the NHS England standard not to provide data where the numbers are smaller than 6 as this may lead to identification of individuals. For this reason and in accordance with The Common Law Duty of Confidentiality, which restricts the identification of individuals who may have received services from the Trust. This it is fundamental to the way the NHS operates, and extends beyond the death of individuals:

The data in question may already be publicly available under other legal regimes

ii. In order to be helpful to you, I have provided below examples of potentially alternative sources of the data you have requested.

• Whenever inquests are held, linked to a Prevention of Future Deaths report (Regulation 28 Report to Prevent Future Deaths), the name of the deceased is published and placed into the public domain by a coroner, though this does not cover every death in the country.
• The data you seek might be reachable via either of the following publicly available links; one shows data by name of the deceased, and the other shows a listing by Trust.
• Reports to Prevent Future Deaths – Courts and Tribunals Judiciary searchable by deceased’s name, and includes where an organisation may have responded
• Reg 28 Reports Tracker Database – Preventable Deaths Tracker

Searchable by any of the fields which can be sorted into alphabetical order, by clicking on any column header. Also available for reuse as a purchase.

iii. The Trust recognises a high level of interest from public in how the public purse is spent on services, and must balance this against disclosure of small numbers and the years in which deaths occurred, which – whilst not directly identifying individuals, would nevertheless give rise to a disclosure of personal data, as follows:

• As we are a small Trust, there is a high chance of recognition/identification of particular individuals/patients by fellow patients or others from the low numbers.
• This masking of low numbers is not a just a question of considering the means reasonably likely to be used by general public, but also the means likely to be used by a determined person with a particular reason to want to identify individuals from data in the public domain now or in the future, and/or gained from other sources.

b. How many of these deaths were reviewed, and how many were judged more likely than not to have been avoidable?

42 of the deaths reported as incidents in 20223/24 were reviewed

As a provider of national non-acute outpatient services, we would not be in a position to always know and/or always be notified when or how a patient died, and, where received, this would often be quite belated. We would also not always be the best placed organisation to confirm avoidability.

The Trust does not hold a deaths register, and does not have the means to extrapolate which deaths were “judged more likely than not to have been avoidable” as we are dependent upon mortality data received by third party agencies, which is inconsistent in its details provision

c. Have you published quarterly reports on learning from deaths on your website, as required by the guidance? Please provide links to the most recent reports.

The Trust confirms that this was not done regularly.  There are mortality reports within some of the Board papers between April 2023 to January 2025 and these may be accessed via the following link (searches within these papers can be undertaken by keying CTRL+F and entering a key word to be searches, such as death, mortality, suicide.  Tavistock and Portman Board Papers

d. Is information on learning from deaths included in your latest Quality Account?

Yes

3. Family Involvement

a. Are families and carers involved in the review process where appropriate?

Where possible, we involve families and carers in the Patient Safety Incident Investigation (PSII) process, but not in all the methods of learning.

b. Please provide the number of deaths that were reviewed in this period (2023/24) where families and carers were involved and engaged in the review. •

Zero

4. Actions and Learning

a. Please provide a summary of all actions taken as a result of the learning from deaths process in the last reporting period.

i. RAG rating reason and rationale now mandatory on assessment form

ii. Distress call rota in place

iii. Introduction of screening process for new referrals

iv. Timely recording of death notification