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How to Streamline the Mortality Review Process and Enhance Continuous Learning from Deaths

Why the right digital mortality review tool can make mortality reviews a catalyst for learning by centralising mortality data.
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| Heather Lowery | Healthcare

Understanding the intricacies of patient mortality is not just a requirement but a fundamental necessity. The insights gained from mortality data pave the way for continuous improvements in patient care and safety protocols. However, managing this data effectively can be a challenge for healthcare institutions without the support of the right digital system.

Previously, before there was integrated digital systems for learning, trusts had to find their own ways to conduct their mortality reviews. Some opted for Excel spreadsheets to collect all the necessary data required. Whilst this method was good at producing numbers, it lacked the depth needed for effective learning.

When other digital systems came into play, they solved some issues, however, other roadblocks soon presented themselves as these digital systems proved clunky and outdated and worked better in theory than practice, unable to handle the intricacies of processes like Structured Judgement Reviews.

What is Needed to Streamline the Mortality Review Process?

By having mortality data all in one place with the ability to link working documents, such as ongoing investigations, the coroner’s report, the Structured Judgement Review (SJR) and more, it rationalises the mortality review process for much more streamlined and reliable data access to enhance learning. It gives users a single repository of mortality data, from entering the initial records at data capture to the mortality review, making the review process and data access more efficient and reliable. Reviewers would no longer need to chase for additional required documents, as everything they need for a full and thorough review is readily available to examine.

When a death happens, it’s vital that the Medical Examiner (ME) can conduct their initial reviews as quickly and as stress-free as possible to ensure that the data is organised, accessible, and conducive to in-depth analysis. To collect data quickly and easily in the short amount of time that an ME has with the patient notes after death, instead of battling with slow and unresponsive interfaces that may crash or refresh, causing the user to begin again, an agile and thorough data capture tool that is highly responsive and reliable, like the InPhase Smart Forms in the Mortality App. This is to ensure that data is collected smoothly and painlessly.

To make the process even easier, and to make sure that no vital piece of data gets missed, required questions are marked with a red asterisk and must be completed before submission. If the user has missed a question, they will be redirected to the missing field and asked to complete it. This ensures that no forms are accidentally sent in incomplete, and the reviewer has all the data they need. The forms can be modified by the administrator to include required fields that help the reviewer ensure that all the data they need is collected and that there is no need for the reviewer to chase for further information at a later date that would delay their review.

In addition, the Structured Judgement Review (SJR) plays a pivotal role in understanding mortality cases thoroughly. InPhase enhances the efficiency of the SJR by sitting behind the ME review form, ready to expand when the user needs it to. Through the help of conditional questions, if an SJR is needed, the user can click ‘yes’ and the entire form expands ready for use that links directly to the mortality record it relates to, so all working documents remain together. In incumbent systems, the SJR remained separate. As a lengthy 4-6 hour process, some clunky and outdated systems might have found it difficult to handle the time it took as well as the vast amounts of information needed to complete it. However, what was once a stumbling block in incumbent systems becomes an easier part of the process in the Mortality App, taking the high responsiveness and well-supported nature of the fast forms and expanding it to support the lengthy SJR process.

With the support of a centralised system, users can automatically trigger further investigations based on specific criteria, such as Patient Safety Incident Response Framework (PSIRF) investigation or avoidable deaths. Through conditional questioning and custom-built workflows that can be built using InPhase, users can push the review through the workflow, all from one place, to ensure the review goes to the right teams for further investigation for the early detection and interventions that are critical in addressing potential issues and preventing similar occurrences in the future.

Enhancing Learning and Improvement with Streamlined Mortality Reviews.

The beauty of having a centralised mortality review tool, like the Mortality app from InPhase, lies in its ability to connect the dots. Incidents, claims, and complaints are no longer isolated entries but integral parts of a larger narrative. This interconnected view provides healthcare institutions with a panoramic understanding of patient experiences. Uncovering patterns and recurring issues becomes second nature, allowing institutions to proactively address systemic problems.

Capturing key learning points isn't just a checkbox in the data entry process; it's a strategic move toward proactive analysis. As healthcare professionals input relevant information during data capture, they are essentially laying the groundwork for comprehensive reviews. These key learning points serve as guidance for the overall mortality review process and can be identified by the ME during the initial review to find insights that lead to actionable change.

By having a digital mortality review app, like the InPhase Mortality app, in place, it supports data-driven learning and decision-making for improvement because everything is in one place. The analytics derived from centralised mortality data provide healthcare professionals with a powerful tool allowing them to analyse trends and patterns. Organisations gain a comprehensive understanding of their practices and can put improvement measures in place. This data-driven approach allows for evidence-based strategies, ensuring a continuous enhancement of the overall quality of care and patient outcomes.


Centralising mortality review processes is not merely an administrative convenience but a transformative approach to healthcare management. By streamlining the review process, institutions can harness the power of data to enhance continuous learning, improve patient care, and ultimately save lives. Investing in advanced, centralised solutions not only ensures better patient outcomes but also contributes significantly to the evolution of healthcare practices, making them more efficient, transparent, and patient-centred.

To see a market-leading patient safety tool and about how Bedfordshire Hospitals NHS Trust are using the Mortality App from InPhase, watch the recording of our latest web conference here.

Andrew Bingham

Chief Operating Officer

Andrew is responsible for our account managers and customer success team, tasked with helping our customers make the most of the opportunities presented by our product features and key business responsibilities of customer retention, adoption and expansion.

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