Mortality Review Programme

The Challenge

Nationally it is recognised that there are major limitations to hospital mortality statistics and how these can be interpreted. The principal method of retrospectively assessing the safety and quality of care received is retrospective case note review. Therefore, to better understand and learn from hospital deaths a standardised process of mortality case note review is required.

The Solution

Since 2014, we have been working with acute, community and mental health trusts in Yorkshire & the Humber on a systematic, evidence-based mortality review programme that can drive improvement in the quality and safety of patient care. The structured judgement case note review method used was developed and validated by Prof Allen Hutchinson with whom the Improvement Academy is working to deliver training in the method directly to front-line staff across the region. It is this methodology that allows trained reviewers to identify and describe the quality of care received and in doing so create a score of that quality.


So far the Improvement Academy has delivered 51 training sessions across 15 acute and mental health trusts within the Yorkshire and Humber region. Over 750 clinical staff have been trained across specialties, departments and roles from consultants and registrars to specialist nurses and patient safety leads. Thematic analysis of the findings of case note reviews is undertaken by the organisations.

The Improvement Academy supports trusts' use of these themes in undertaking targeted improvement work and share the knowledge emerging with all participants. Themes pertinent to regional learning is highlighted and disseminated. The Improvement Academy also organises events bringing together regional trusts to support them with tools and methodologies to translate the themes into improvement initiatives. Some of the learning and improvement so far has been captured in the case studies (featured on the right).

The National Programme

In response to several national reports and expert recommendations, NHS England has commissioned a National Mortality Case Record (NMCRR)Programme to support the standardisation of, and learning from, mortality case note reviews in NHS Acute Trusts. Such a national programme requires a training programme to support uptake and the spread of learning and best practice. The Yorkshire and the Humber programme provides the structure, the resources and the expertise that can only help with the implementation of a national programme.

Since 2016, the AHSN Improvement Academy has been working in partnership with the Royal College of Physicians (RCP) to deliver the national programme. It aims to roll out a standardised way of reviewing the case records of adults who have died in acute hospitals across England and Scotland. The programme's main purpose is to improve understanding and learning about problems in care that may have contributed to a patient's death. This national body of work will allow organisations to identify common themes individual to their environment, whilst also building a growing national understanding of deficiencies in patient care. The aim is to nurture continuous quality improvement within organisation and support sharing of this practice.

In March 2017, the Department of Health announced a National Mortality Framework to learn from the care of patients who die. The framework recommended the Improvement Academy's Structured Judgement Review methodology as a key case note review methodology.

For further information please contact Dr Usha Appalsawmy via email on usha.appalsawmy@yhahsn.nhs.uk.

Improvement Fellows

Find out more about some of the people who are contributing to patient safety and quality improvements on the Improvement Fellows page.

Background Reading

Health Technology Assessment - 2010

BMJ Quality & Safety Online First - 2013

Keogh Report - 2013

CQC Report - 2016

National Mortality Framework Guidance - 2017

Review Tools

SJR Guide & Data Collection Tool

Press Releases & Newsletters

January 2018 - Avoidable deaths data

July 2017

March 2017

November 2016

Training Dates

Tier One training
 Location  Date 
 Liverpool 15th November 2017 
 Sheffield 1st December 2017 
 Carlise 7th December 2017 
 Newcastle 17th January 2018
 Middlesborough   25th January 2018 
 Manchester 1st February 2018
 London 15th February 2018

Impact Case Studies

North Lincolnshire and Goole

Doncaster and Bassetlaw

Harrogate and District 



Dr Usha Appalsawmy