1562 LET’S TALK ABOUT DEATH: IMPLEMENTING GUIDANCE ON LEARNING FROM DEATHS AT HOMERTON HOSPITAL

Abstract Introduction The National Quality Board published the first Guidance on Learning from Deaths in March 2017, which stated the aim of mortality review processes across NHS Trusts and provided a framework in identifying, reporting, investigating and learning from deaths in care. Homerton Healthcare NHS Foundation Trust considered how best to implement the Guidance: record mortality reviews, increase engagement within the Trust and disseminate learning. Method Whilst paper-based mortality reviews had already been conducted by some specialties, there was no Trust-wide process to record data and learnings. In 2018, an in-house electronic Mortality Review Tool was built by clinicians and IT team incorporating the use of CESDI (Confidential Enquiry into Stillbirths and Deaths in Infancy), a scoring methodology used to document quality of care and impact on outcome. Ongoing training for the tool is provided to medical staff and is now used by all specialties. A quarterly multidisciplinary mortality newsletter entitled “Let’s Talk About Death” was launched and is now published on the intranet, available for all members of the Trust. Anonymised clinical case examples are used to illustrate learning points and teaching on death and dying. Results Percentage of completion of mortality reviews across the Trust increased from 82% to 99% with the implementation of the electronic Tool in comparable quarters (Q1 2018/2019 to Q1 2022/2023). Consultant-led CESDI scores rose from 76% to 98% over the years (2018/2019 to 2021/2022). The newsletter has led to regular collaboration with all teams involved in supporting a patient with life-limiting illness; has encouraged multidisciplinary focus on dying and has provided a leadership opportunity to geriatric medicine trainees who edit the newsletter. Conclusion The Trust’s response to the Guidance has resulted in measurable improvement in data recording and engagement with mortality reviews across all specialties and has reinforced the culture of learning from deaths.