Mortality Review Toolkit

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Introduction

This Mortality Review Toolkit provides a structured, auditable approach to reviewing deaths across health and social care settings. It supports use of validated methodologies (for example the RCP Structured Judgement Review), proportionate screening and triage, family engagement and closed‑loop learning to identify care quality issues, system factors and improvement actions.

Legislative Requirements

• Care Act 2014 — deaths of people with care and support needs should be screened for safeguarding, learning and service improvement; partnership working with Safeguarding Adults Boards and commissioners is required where thresholds are met.
• Mental Capacity Act 2005 — ensure decisions preceding death complied with capacity assessments, best‑interest decisions, lawfully recorded advance decisions and DNACPR processes; document any deprivation of liberty or restrictive practice.
• Data Protection Act 2018 / UK GDPR — mortality reviews process special category health data: identify lawful basis and Article 9 condition, apply data minimisation, maintain secure access and audit trails, and agree information‑sharing protocols with coroners and external partners.
• Notification of Death Regulations (2019, amended) — comply with statutory reporting requirements to coroners/procurator fiscal where applicable and local regulator notification obligations.

Regulatory Guidance

• CQC (England) — expects systematic mortality review arrangements that support Regulation 12 (safe care), Regulation 17 (good governance) and demonstrate staff competence in structured review methods. Escalate to safeguarding, coroners and commissioners where required.
• Care Inspectorate (Scotland) — mortality review activity is assessed via statutory notifications, adverse event frameworks and inspection against Health & Social Care Standards; decisions to review must be documented and learning evidenced.
• Care Inspectorate Wales (CIW) — requires prompt notification of deaths, proportionate structured review and evidence that learning informs governance, staff development and service improvement.

Statutory Guidance

• Accountability — organisations must demonstrate how deaths were screened, whether care contributed, actions taken to mitigate risk and how senior oversight and governance assured closure.
• Duty of Candour — apply where an unexpected or unintended incident caused or contributed to death.
• Safeguarding — trigger safeguarding referrals where abuse, neglect or systemic failure is suspected.
• Reporting — notify regulators, coroners/procurator fiscal and commissioners as required by law and local policy.

HealthCare Guidance

• National Guidance on Learning from Deaths (England) — systematic identification of deaths in scope, SJR use, public reporting and board scrutiny.
• Scotland — NHS Boards must use the National Framework for Reviewing and Learning from Adverse Events and Healthcare Improvement Scotland guidance to integrate mortality reviews into adverse‑event systems.
• Wales — All‑Wales Learning from Mortality Review Model Framework mandates stage‑based review, Medical Examiner scrutiny and board governance.
• Clinical guidance — use relevant NICE, SIGN and speciality guidance as clinical benchmarks when assessing quality of care prior to death.

Evidence Based Practice

• Adopt validated, consistent review methods (SJR or equivalent) conducted by trained reviewers independent of direct care.
• Early triage of all deaths to determine review level (no review, rapid local review, SJR, significant adverse event or external referral).
• Engage families and carers sensitively, applying Duty of Candour and offering opportunity to contribute to reviews.
• Focus on systems learning: identify contributory factors, not individuals, and translate findings into measurable improvements.
• Ensure multidisciplinary input and link findings to relevant clinical guidelines and evidence base when assessing care quality.

Clinical governance and Safety (NHS)

• Embed mortality review outputs into risk registers, quality improvement programmes and board reporting with named owners for actions and verification evidence.
• Report routine metrics: numbers screened, number subject to SJR, percentage with problems in care, actions taken and impact monitoring.
• Provide training and quality assurance for reviewers; maintain an internal peer‑review/second‑opinion process for consistency.
• Ensure linkage between mortality reviews, incident reporting, safeguarding processes and PSIRF-aligned investigations.

PSIRF

• Apply PSIRF principles where deaths indicate patient safety incidents: proportionate, learning‑focused reviews rather than blame, with escalation thresholds defined for rapid review, thematic analysis and in‑depth investigation.
• Document rationale for level of review and integrate mortality review plans within the Patient Safety Incident Response Plan (PSIRP).

Using the Toolkit — Practical Steps

1. Screen — record all deaths, capture basic demographics, location, cause (if known) and immediate safety flags (unexpectedness, possible neglect, care escalation issues).
2. Triage — apply predefined criteria to determine review level (no further review, rapid local review, SJR, significant adverse event or external referral).
3. Notify — inform internal governance leads, safeguarding, coroners/procurator fiscal and commissioners as required; record legal bases for data sharing.
4. Review — conduct the selected review (SJR or equivalent) by trained, independent reviewers; include multidisciplinary input and family perspectives where appropriate.
5. Action — produce an action plan with owners, deadlines, verification evidence and clear measures of impact.
6. Communicate — apply Duty of Candour when required; provide families with compassionate explanations and information on learning and actions.
7. Assure & Monitor — track completion of actions, measure outcomes, report to boards and safeguarding partners, and feed thematic learning into training and policy change.

Templates & Data Fields (recommended)

• Event reference, status, priority and review level (screened, rapid review, SJR, SAE)
• Reporter, deceased identifiers (pseudonymise in reports where appropriate), DOB, comorbidities, DNACPR/ACP/DoLS flags
• Date/time of death, location, immediate cause (if known) and admitting service
• Initial screening rationale and triage outcome with timestamps
• Review records: reviewer name/role, methodology used (SJR), phases of care reviewed, explicit written judgements
• Family contact log, contributions and consent status
• Findings: contributory factors, problems in care, alignment with guidelines
• Action plan: description, owner, due date, completion evidence and impact metrics
• Notifications: coroner/procurator fiscal, safeguarding, commissioners and regulatory returns
• Data protection fields: lawful basis, Article 9 condition, retention period and access controls

Monitoring, Audit and Reporting

• Maintain a mortality review register to track screening, open reviews, ageing and overdue actions.
• Dashboard metrics: deaths screened, reviews completed (by type), % with problems in care, time to review completion, action closure rates and family engagement rates.
• Audit quality of reviews: consistency of judgements, documentation completeness and evidence of closed‑loop improvement.
• Provide regular reports to Quality & Safety Committees and Boards demonstrating trends, learning and impact of actions.

Value Proposition

• Delivers a single, auditable pathway to screen, review and learn from deaths consistently across services.
• Supports compliance with statutory and regulatory duties (Care Act, MCA, CQC/CI/CIW expectations) and national review frameworks.
• Focuses on system improvements through actionable recommendations, measurable impact and board‑level assurance.
• Enables compassionate family engagement and transparent communication where harm or unexpected outcomes occur.

References

• Care Act 2014
• Mental Capacity Act 2005
• Notification of Death Regulations 2019 (amended)
• National Guidance on Learning from Deaths (NHS England, 2017)
• Royal College of Physicians — Structured Judgement Review (SJR) / NMCRR programme
• All‑Wales Learning from Mortality Review Model Framework
• National Framework for Reviewing and Learning from Adverse Events (Scotland) / Healthcare Improvement Scotland
• NCEPOD; SIGN; NICE guidance
• Patient Safety Incident Response Framework (PSIRF)
• UK GDPR / Data Protection Act 2018

Disclaimer

Radar Healthcare provides configuration templates and implementation guidance to support effective use of the platform. Any clinical, regulatory or data protection examples are for general guidance only and do not constitute legal, clinical or compliance advice. Radar Healthcare acts as a data processor under customer instruction. The customer, as data controller, remains responsible for assessing and managing risks, determining lawful processing, and ensuring compliance with applicable regulations.