Review of Death Policy

Reviews of death are one component of an overall approach to clinical governance that includes clinical risk management, clinical incident management and complaint management. The National Safety and Quality Health Service (NSQHS) Standards (external site) (second edition) devote the entirety of Standard 1 to the importance of clinical governance within health service organisations.

Reviews of death provide valuable opportunities to examine the care provided to patients; to identify if the care was appropriate, whether it could be delivered differently or improved, and to evaluate the quality of end-of-life care. Reviews of death may also identify cases where sub-optimal care may have contributed to the death of a patient, and that death may have been preventable.

A revised Review of Death Policy (MP 0098/18) and its related and supporting documents came into effect on 1 January 2019. The revised Review of Death Policy supersedes the previous Western Australian Review of Death Policy (OD 0448/13) and is applicable to Health Service Providers, and to private health care facilities that have a licence requirement to comply with it.

The purpose of the Review of Death Policy is to ensure that Health Service Providers implement consistent policies, processes and systems for the recording and review of patient deaths, so as to identify potentially preventable deaths and opportunities for improvement in the delivery of health services (including the quality of end-of-life care). Any preventable deaths identified via the review process are required to be notified as Severity Assessment Code (SAC) 1 clinical incidents and investigated as per the Clinical Incident Management Policy (if this has not already occurred). The Review of Death Policy also has a relationship to the Western Australian Audit of Surgical Mortality (WAASM).

Scope

The Review of Death Policy applies to all patient deaths that have not been referred to the WAASM or notified as SAC 1 clinical incidents including, but not limited, to those:

  • That occur in hospitals in Western Australia
  • That occur under the care of Hospital in the Home (HITH) and Rehabilitation in the Home (RITH) services, and
  • Involving Nursing Home Type category and Care Awaiting Placement patients in Western Australian public hospitals.

This includes deaths of patients that are not for resuscitation (NFR), not unexpected (e.g. terminally ill and palliative care patients), or that occur in Emergency Departments.

Health Service Providers and private health care facilities are also encouraged to review deaths of patients who received healthcare in ambulatory or community care settings (e.g. community mental health patients, terminally ill patients in the community).

Reporting requirements

The timeframes for the review of patient deaths (four months from the date of death) and the provision of six-monthly reports to the Patient Safety Surveillance Unit (PSSU) remain unchanged in the revised Review of Death Policy.

Periodic reporting to the PSSU is due by 31 May (for deaths during the preceding period July to December) and 30 November (for deaths during the preceding period January to June). The reporting templates for the Review of Death Policy have been revised, and additional information is required to be provided in respect of patient deaths that have been notified as SAC 1 clinical incidents.

Please note that the requirements of the previous Western Australian Review of Death Policy (OD 0448/13) apply to all patient deaths that occur up to and including 31 December 2018 and fall within the scope of that policy. All patient deaths that occur from 1 January 2019 onwards are to be reviewed in accordance with the revised Review of Death Policy (MP 0098/18). Health Service Providers and private health care facilities may choose to review patient deaths that occur before 1 January 2019 in accordance with the revised Review of Death Policy if they wish.

More information

Patient Safety Surveillance Unit
Email: pssu@health.wa.gov.au

Produced by

Patient Safety Surveillance Unit