Impact Case Study: Doncaster and Bassetlaw Hospitals NHS Trust


Doncaster and Bassetlaw Hospitals NHS Foundation Trust serves a population of more than 420,000 across south Yorkshire, north Nottinghamshire and the surrounding areas and runs three hospitals:

  • Doncaster Royal Infirmary
  • Bassetlaw Hospital
  • Montagu Hospital

The trust uses the Improvement Academy’s Structured Judgement Review (SJR) methodology for systematic mortality reviews.

The process

  • Specialties with 10 or fewer deaths per month aim to review 100% of all their deaths. Specialties with consistently greater than 10 deaths per month are expected to review a sample of at least 10 deaths.
  • A mortality screening tool developed by the trust’s mortality group was introduced in March 2016. The tool is used to help case selection for specialities, such as general medicine, which expectedly have a high number of deaths.
  • Any death of a patient with learning disability or any patient who died in the context of an elective admission get an in-depth review using SJR.
  • Any 1st stage review with a score of <3 is brought to the Mortality Case Review meeting for a second stage review. Actions are taken accordingly and messages are fed back to specialities via individual governance processes.
  • Reviewers are supported in their skill development.
  • The mortality group produces quarterly reports of the reviews and learning outcomes. This is fed back to the respective specialities and the care issues identified are used to drive quality improvement initiatives.
  • Exemplary practice of either individuals or ward teams is always recognised by way of a letter from the Deputy Medical Director
  • The Mortality Monitoring Group and Mortality Case Note Review group meet monthly.


Example of themes and quality improvement initiatives

The most common theme was that of missed opportunities in recognising end of life therefore resulting in unnecessary interventions in a dying patient. This led to an awareness raising campaign across the Trust via a variety of routes such as lunchtime lectures, specialty presentations and individual leadership. The trust is already seeing an improvement in timely recognition and management of the dying patient.
Admissions from care homes and other community care settings that are deemed to be unnecessary are analysed and information fed back via the Clinical Commissioning Groups.
Improved coding of learning disability patients through better liaison with the Learning Disability Specialist Nurse

The Future

More timely reviews. This is crucial should any issues with care be highlighted and the need for duty of candour to be applied.

Discussions are being held to identify a process for ensuring any care issues highlighted by family members prior to death trigger the involvement of the family in a case review.

Agree the format for a report to be made to the Board on avoidable deaths.


If you would like an update on the progress of the above trust with regards to mortality reviews and quality improvement initiatives, please contact