Death Procedures and Processes - FOI Response Register

I am interested in establishing how NHS boards deal with the deaths of patients that have been brought to its attention by staff on the Datix system, through complaints of patients, families or any other means.

If a patient dies in Hospital, that is recorded in the patient’s physical health record and on Trak. The registrar provides data for all people who have died who are Shetland residents, so we can update our records and not send out inappropriate appointments etc.

Hospital Standardised Mortality Ratio data is included in the quality dashboard that goes to Clinical Governance Committee and Health Board. If there is a significant event, where there could have been irreversible harm as a result of the care that the person received, then this will be investigated (whether the patient died in the community or in the hospital setting). Such cases will be discussed with the Procurator Fiscal.

1. All processes by which concerns about the circumstances surrounding patient’s death can be reported to the board.

For example, I understand a patient’s death could be reported through the staff Datix system but I also understand this might not be the only way particularly if families or non-staff have made the complaint or given notice to the board.

Datix Adverse Event Report

Formal Complaint process

2. Please list all of these processes with an explanation attached about how each one works (who has to make the report the death etc and how they do it).

Any adverse event, including death is reported as per procedures in Learning from Adverse Event Reporting and Review Procedure -   Appendix 1, page 24 outlines the process for any staff reporting/managing an adverse event

Below link is not a real link it’s a intranet link. If we release it needs to be an attached pdf.

https://intranet.nhsshetland.scot.nhs.uk/departments/clinicalgovernance/documents/2021-04-22-LearningfromAE-ReportingandReviewProcedureJanuary2021v1.6Approved.pdf

Formal complaints are made and handled as per Boards Complaints procedures

https://www.nhsshetland.scot/rights/patient-feedback-complaints/3

3. The number of patient deaths the board has been notified of broken down by type of notification process (the list of which you will have provided in response to request 1).

I am looking for this figure to be broken down by year in the last five years [2019, 2020, 2021, 2022, 2023 and 2024* so far]

With regards to death notified as per Q1 see response to Q3.

4. The number of patient deaths the board has gone on to investigate as a result of being notified through one of the processes.

I am looking for this figure to be broken down in the last five financial years. [2019, 2020, 2021, 2022, 2022 and 2024*so far]

Deaths reported via Adverse Event notifications, including those reported to Healthcare Improvement Scotland (HIS) from date of requirement to report (January 2020) to FOI submission date, are noted below

Reported during financial year

2019/20                Nil

2020/21                Nil

2021/22                1

2022/23                Nil

2023/24                3

5. If any investigation has had an outcome, then please disclose what the outcome was [for example, investigation complete, investigation pending or anything like that

In accordance with FOISA s 16(1), NHS Shetland confirms that it holds the information requested but that it is exempt from disclosure under FOISA s 38(1)(d) as the information constitutes the health record of a deceased person.