Reducing avoidable deaths in inpatient settings (fail to rescue) from physical health conditions Mersey Care NHS Trust

Core Team Details NameRoleContact Details Joanne ScoltockModern Matron – Physical Wendy Copeland-BlairHead of Performance Dr Deep MajumdarConsultant Psychiatrist – Older Adults Eifion IngmanLead for Nursing and Quality (Local Division) Dale WilliamsModern Matron - Primary Health Care (Secure Division) Tony CrumptonHead of Safety and Joanna MorganPhysical health Lee KnowlesChief Janet Hussein-AliHead of Learning and DevelopmentN/A Lisa KnightMortality Collaborative

What was your original project Aim and has this changed? Original AIM: To reduce the number of avoidable deaths for inpatients to zero from 30 September 2014 onwards in participating wards. Details of changes: Current aim “To reduce the number of avoidable deaths for inpatients to ‘zero’ from 28 February 2015 onwards in participating wards, through the systematic identification and management of physical health deterioration.” Explanation of changes: Further detail added to the aim statement to be explicit about the scope of the work we were doing and timeframes amended to reflect the extent of the work required to implement the improvements necessary to impact on the agreed outcome measure.

Driver Diagram

Measures and Data MEWS implementation: Increased staff confidence. 96% of staff said “improved my nursing skills”. Staff also reported that it helped them to “speak the same language” as acute trusts and ambulance staff.

Key Achievements & Lessons Learnt MEWS roll out nearing completion (increased staff confidence and benefits to patients e.g. commenced on hypertensive medication following escalation of observed high blood pressure) Successful testing of MEWS short form audit and agreement on implementation process within local division. Addition of a performance indicator relating to MEWS compliance to the trust’s performance assurance framework. Successful testing of new physical health 72 hour safety check form, due to start work with patient safety team to agree implementation in near future. Completion of a review into our wider compliance with Resuscitation Council (UK) standards for mental health trusts and recommendations for improvement made to the Executive Team. System wide improvements Joint clinical and improvement leadership approach with support from small group of interested and enthusiastic project team members and wider reference group on whom we could call for advice. Would have spent more time thinking about engagement strategy at the beginning of the project.

What should AQuA do differently Chase us up more regularly for checkpoint reports to help us to maintain momentum and a better line of sight on how our projects are progressing.