The programme

A pioneering programme, recognised by the Royal College of Physicians (RCP) to support our members in learning from patient deaths and making improvements in patient care.
Through our Improvement Academy, we are working with Trusts in the region to develop a standardised systematic evidence-based mortality review programme, This programme delivers training in reviewing case notes of patients who have died and supports members to make quality improvements as a result of their analysis and learning.


This is both a patient and an NHS priority. In response to several national reports and expert recommendations, NHS England plans to commission a National Retrospective Case Record Review Programme to support the standardisation of, and learning from, mortality case note reviews in NHS Trusts. This will require a training programme to support uptake and the spread of learning and best practice.The Yorkshire and Humber programme provides the structure, the resources and the expertise to help with the implementation of a national programme.

How are we helping?

Nationally it is recognised that there are major limitations to hospital mortality statistics and how these can be interpreted. The principal method of 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. Since the beginning of 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.
We understand the concept of ‘avoidable death’ creates some difficulty. However, current legislation and statutory responsibility creates a mandate to develop a robust, reliable and validated method of identifying avoidable death so that learning can take place.
The structured judgement case note review method used was developed and validated by Prof Allen Hutchinson with whom our Improvement Academy is working to deliver training in the method directly to front-line staff across the region.

This methodology allows trained reviewers to identify and describe the quality of care received and in doing so create a score of that quality. This method, on rare occasions, will also enable the reviewer to make explicit statements about the avoidability of death.

Through our facilitated regional network, we enable all Yorkshire and Humber trusts to access nationally recognised training in systematic mortality case note review (MCNR). We support our trusts to analyse findings, identify regional themes and to turn that learning into quality improvements.

The regional programme will link to the National Retrospective Case Record Review Programme and ensure that Yorkshire and Humber continues to take a lead nationally in improving quality of care.

Our impact to date

Through our Improvement Academy, we have been supporting member organisations by;

  • Delivering over forty training sessions across trusts within the Yorkshire and Humber region.
  • Training over 500 clinical staff across specialties, departments and roles from consultants and registrars to specialist nurses and patient safety leads.

This programme has now been recognised by the RCP

Next Steps


  • We are working with the RCP to improve patient care across the country using our nationally recognised evidence-based case note review linked to quality improvement
  • Regionally we will support members by delivering masterclasses in understanding hospital mortality statistics and using case-note reviews as a solution to understanding quality and safety issues around mortality.
  • We will use our knowledge to highlight good quality care, which can be celebrated and fed-back to teams, developing and disseminating case studies of acute trusts actively improving care around an identified regional theme.
  • We will use learning from healthcare deaths to improve patient care and reduce costs to member trusts associated with complaints and litigation (currently over £1.4bn annual compensation costs for NHS in England and over 3,000 complaints each week)

Our Improvement Academy can offer Trusts:

  • Masterclasses in understanding hospital mortality statistics and using case-note review as a solution to understanding quality and safety issues around mortality.
  • An opportunity through standardised case note review to highlight good quality care which can be celebrated and fed-back to teams. Where things “go well” this can then be spread to other areas.
  • Train the trainer sessions to train senior health care professionals to deliver rwegional and local training in SJR
  • Acting on emergent patient safety themes by supporting teams with Quality Improvement initiatives that can be shared across our network.

For further information about these training sessions please contact Dr Usha Appalsawmy on 01274 383955 or

Click here for more information about the Improvement Academy’s work in this area.