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 Datix 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







Head of Integrated Governance - Safety


Claire Brockbank



Patient Safety & Mortality Clinical Manager


Jenna Jamison

Patient Safety Manager

Justine Collins



Generic Mortality and Incident Practitioner

Suzi Lloyd-Ellington



Generic Mortality and Incident Review Practitioner

Vicky Rotherham



Generic Mortality and Incident Practitioner Catherine Fisher

LeDeR Mortality and Incident Review Practitioner

0.4 WTE

Eileen Streets



LeDeR Mortality and Incident Review Practitioner

0.4 WTE

Eifion Ingman









Mortality and Incident Review Manager


Kim Bennett



Serious Incident Co-ordinator


Jeannie Dunn


Mortality and Incident Data Technician


Karen Maguire


Risk Co-ordinator

Chris Jones