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• A Data Quality dashboard is embedded within our • 17 in the third quarter;
Data Quality Process which includes key data items
• 14 in the fourth quarter.
from throughout the patient pathway, to monitor data
quality and facilitate improvement
By 1st April 2018, 39 case record reviews and two
• Workshops and refresher training sessions arranged investigations have been carried out in relation to the
to ensure staff are fully aware of the importance of 65 deaths included in the previous paragraph. Whilst
Data Quality and the integrity of the data is accurate many adult trusts only conduct mortality reviews on
at source cases where deaths are unexpected or flagged through
an incident, it is the policy of Alder Hey that all inpatient
• The annual audit plan has covered a number of
deaths are reviewed.
patient checks including
- A&E waiting times
In two cases a death was subject to both a case record
- Demographic changes review and an investigation. The number of deaths
- Missing NHS numbers in each quarter for which a case record review or an
- 18 weeks Referral to Treatment (RTT) & Outcomes investigation was carried out was:
- Duplicate registrations • 18 in the first quarter;
- Ethnicity monitoring • 14 in the second quarter;
- Pathway starts
• 7 in the third quarter;
- GP checks
• 0 in the fourth quarter (due to be completed in the
2.2.9 Information Governance (IG) coming period)
Toolkit Attainment Levels None (representing 0%) of the patient deaths during the

reporting period are judged to be more likely than not to
Alder Hey’s Information Governance Assessment have been due to problems in the care provided to the
Report overall score for 2017/18 was 76% and was
patient.
graded as ‘satisfactory’ (green). Additionally, the Trust’s
internal auditors assessed compliance with the IG
These numbers have been estimated using the
Toolkit and reported ‘significant assurance’.
mortality review process established in Alder Hey
2.2.10 Clinical Coding Error Rate Children’s NHS Foundation Trust. Every child that dies
in the Trust has a Hospital Mortality Group review (a
group consisting of professionals from across the Trust
Alder Hey Children’s NHS Foundation Trust was
and specialties) and usually at least one departmental
required to undertake an Information Governance
review prior to this.
Toolkit audit during the reporting period; the error rates
reported in the latest published audit for that period for
Although there were no avoidable deaths in the
diagnoses and treatment coding, i.e. clinical coding,
reporting period over this time, that have been reviewed
were:
so far, the Trust has continued to learn from our
• Primary Diagnoses Incorrect 4.5% mortality process and instituted appropriate changes
• Secondary Diagnoses Incorrect 19% (even though the issue addressed by the change
was not thought to have contributed to the patient’s
• Primary Procedures Incorrect 7% death). In our process, we also identify external factors
• Secondary Procedures Incorrect 10% impacting on the children who then die in the Trust.
As part of its process, the Hospital Mortality Review
The results should not be extrapolated further than the Group identifies children who, with early intervention
actual sample audited and the services audited during or education, may not have died. Of course, such
this period included: factors are also examined by multi-agency Child Death
Overview Panels (CDOP). External factors impacting
• 200 Random Finished consultant episodes
on children that then die at Alder Hey include external
2.2.11 Learning from Deaths traumatic incidents which could have been avoided
(in which circumstances the conclusion of HMRG
is that death could have been prevented). This is
During the period 1st April 2017 to 31st March 2018, 65
classed as an example of a ‘potentially modifiable
inpatients died. This comprised the following number of
factor’. This is also highlighted by co–sleeping resulting
deaths which occurred in each quarter of that reporting in a SUDI (sudden unexplained death of an infant).
period:
There is currently a campaign ongoing in Merseyside
• 18 in the first quarter; highlighting the risks of co-sleeping that should impact
on the SUDI presentations
• 16 in the second quarter;

Alder Hey Children’s NHS Foundation Trust 102 Annual Report & Accounts 2017/18