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Case reviews

At King’s College Hospital we routinely carry out reviews of the quality
of care provided to someone before their death. We review in detail a
proportion of all deaths so that we can learn, develop and improve our
care.

We review all deaths where safety incidents may have occurred (see
below) or where bereaved families, carers or staff have raised a
significant concern about the quality of the clinical care provided. We
also review all deaths when the death was unexpected, such as after
a routine operation.

In addition, we review all deaths where the person had a severe
mental illness (such as schizophrenia) or learning disability. This is
because we want to ensure that King’s College Hospital provided all
the care these patients needed for their mental, as well as physical,
health whilst they were in hospital here, and that our Adult
Safeguarding service was involved where needed.

If reviews identify any potential problems with the care provided, we
will conduct a detailed patient safety investigation as described below
and contact the family or carers to share the findings with them.

Patient safety incidents and investigations

In a small percentage of cases, there may be concerns that a death
could be related to a patient safety incident. A patient safety incident
is any unintended or unexpected incident, which could have, or did,
lead to harm for one or more patients receiving healthcare. The
purpose of a safety investigation is to find out what happened and
why. This is to identify any potential learning and to reduce the risk of
something similar happening to any other patients in the future.

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