Mortality and Incident Review Team

Their aim is to provide the clinical divisions with timely and robust reviews based on sound methodology to maximise learning but also support families and colleagues with a compassionate approach throughout the process. A restorative “Just and Learning” approach is embedded ensuring they seek to discover contributing factors rather than apportion individual blame. This approach enhances learning and improvement, allows organisations to examine incidents openly (without fear of inappropriate sanction) and supports those affected. 

The team review care and treatment by completing triage screening following a report of a death on the Radar incident reporting system. They may then complete a more in-depth review called a Structured Judgement Review where this is indicated to provide insight on an individual’s care and treatment to provide learning to the organisation.

The Mortality Incident Review Practitioners (MIPs) findings are then considered during a mortality MDT clinically led by the Director of Patient Safety or a deputising Consultant Psychiatrist. Clinical teams are invited to participate where possible to discuss those cases relevant to their service area. Learning is shared with the teams and back to the division as part of this process.

The MIPs may also carry a caseload of SI (Serious Incident) reviews which we are commissioned to carry out on behalf of the clinical divisions, supported by divisional based staff.

Whilst some MIPs work generically, carrying out reviews across the range of services the Trust provides, other members of the team are specifically dedicated to complete Learning Disabilities Mortality Reviews (LeDeR) on behalf of several local CCGs as a part of the local contribution to the national LeDeR review initiative now managed by NHS England.