Mortality and Incident Review Team
The Mortality and Incident Review Team supports the Trust goal of learning from deaths to improve the safety and quality of patient care.
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.
Key functions |
Contacts |
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Telephone |
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Head of Integrated Governance - Safety |
Claire Brockbank |
0743512560 |
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Patient Safety Manager |
Alys Holmes |
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Patient Safety Lead |
Eifion Ingman |
07966883215 |
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Patient Safety Lead |
Lesley Roche | lesley.roche@merseycare.nhs.uk | |
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Patient Safety Lead |
Carla Pearce | 07971388267 | carla.pearce@merseycare.nhs.uk |
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Patient Safety Lead |
Tracy Grimes | tracy.grimes@merseycare.nhs.uk | |
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Patient Safety Lead |
Lorna Green | 07787510918 | lorna.green@merseycare.nhs.uk |
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Serious Incident Co-ordinator |
Jeannie Dunn | Jeannie.Dunn@merseycare.nhs.uk | |
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Mortality and Incident Data Technician |
Karen Maguire |
07827985203 |
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Mortality and Incident DataTechnician |
Chris Jones |
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Serious Incident Team
The Patient Safety Team supports the organisational aim of learning from patient safety and all incidents to improve the safety and quality of patient care.
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As a team they have established and maintain incident and risk management systems. They work closely with divisions to ensure that the Trust meets it's key performance indicators for serious incidents and Duty of Candour and that trends in serious incidents and the findings of related reviews are reported within the organisation. They liaise closely with our key external stakeholders – Clinical Commissioning Groups (CCG), NHS England/Improvement, other provider organisations, police and regulators to ensure that reviews are carried following due process and within the national serious incident framework. Their aim is to assist and support the clinical divisions to conduct timely and robust reviews based on sound methodology with a proactive approach to learning from incidents, whilst supporting the patients, families/carers and colleagues with compassion throughout the process. A restorative “Just culture and Learning” approach is embedded in the serious incident process ensuring that an environment is created where staff feel supported and empowered to learn when things do not go as expected and where systemic contributing factors are identified rather than apportioning blame. This approach aims to allow the Trust to examine incidents openly (without fear of inappropriate sanction) and compassionately supports those affected so that risks are addressed and learning is maximised. The Patient Safety Team, on occasion, may directly commission and undertake serious incident reviews where there is a conflict of interest within or between divisions and will oversee the conduct and participation in any external reviews. Serious Incidents and Duty of Candour clincis are now availble every Tuesday and Thursday afternoon between 13:30 and 15:30. The serious Incident clinics have been arranged to support lead reviewers undertaking learning reviews as part of the SI framework. To book a place on one of these clinics please contact: seriousincidents@merseycare.nhs.uk. |
Key functions |
Contacts |
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Name |
Telephone |
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Head of Integrated Governance - Safety |
Claire Brockbank |
07435412560 |
Claire.Brockbank@merseycare.nhs.uk
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Patient Safety & Mortality Clinical Manager |
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Serious Incident Lead |
vacant |
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Serious Incident Co-ordinator |
Jeannie Dunn |
01925 664452 |
Jeannie
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| Chris Jones | Mortality & Incident Data Technician | Chris Jones@merseycare.nhs.uk | |
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Karen Maguire |
Mortality & Incident Data Technician | Karen.Maguire@merseycare.nhs.uk | |
SI Training for 2022/23 – each session is a two day course – cohort of 14 staff
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23 / 24 August 2022 |
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27 / 28 September 2022 |
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02 / 03 November 2022 |
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01 / 02 December 2022 |
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24 / 25 January 2022 |
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28 / 29 March 2022 |