Recommendation 105

Incident reports and standardised mortality ratio

Consideration should be given to whether information from incident reports involving deaths in hospital could enhance consideration of the hospital standardised mortality ratio.

As part of Professor Sir Bruce Keogh’s Review of the Quality and Safety of Care and Treatment Provided by 14 Hospital Trusts in England, NHS England provided detailed reports from the National Reporting and Learning System for each of the 14 trusts that were looked at. That process was informative and resulted in key lines of inquiry for the inspection teams on the ground. It in effect acted as a pilot for a stronger method of utilising NRLS data in Care Quality Commission inspections. It was also found that data from the National Reporting and Learning System correlated well with other datasets to indicate problems with safety. NHS England will work with the Care Quality Commission to build on the learning from Sir Bruce Keogh’s Review to address this.

NHS England is also leading work to develop proposals for ensuring every trust undertakes retrospective case note reviews of patient deaths according to a consistent methodology to further encourage learning from adverse events. This will help trusts address common issues associated with avoidable hospital mortality, such as management of deteriorating patients.


NHS England was already exploring the development of a standardised process for supporting the NHS to undertake retrospective case note review. Introducing a national standard approach for undertaking case note review would build on innovative work at the London School of Hygiene and Tropical Medicine and has the potential to enable NHS Trusts to develop a better understanding of actually avoidable deaths.

  • Although case note reviews are a “gold standard approach” they can be time and resource intensive.
  • NHS England are moving ahead now to develop a national rate and produce an estimate number of avoidable deaths for each hospital. This will be done by someone independent of Trusts and the numbers will be made public. Trusts will be expected to report annually to the Secretary of State for Health on their actions to reduce avoidable deaths.