Written question WQ84843

The measure on mortality reviews was withdrawn from the NHS Delivery Framework from April 2020. Welsh Government therefore ceased central collection of this data and does not hold any information on the number and timings of mortality reviews beyond March 2020. This reflects the introduction of a new role of Medical Examiner being introduced in England and Wales. Medical Examiners will undertake an initial, independent, scrutiny of all deaths not referred to a coroner. Where their scrutiny identifies any potential issues or concerns in relation to care provided, they will refer to the provider’s clinical governance systems for appropriate further review, which may engage the mortality review process within health boards. The Medical Examiner service is being introduced incrementally until it is fully established on a statutory basis.

In April 2020, in light of the pandemic, and whilst the Medical Examiner Service is being incrementally introduced, the Deputy Chief Medical Officer (DCMO) wrote to NHS Medical Directors asking them to continue to undertake mortality reviews for those deaths where there may be a concern or unusual circumstances. The DCMO stated that the reviews carried out should be proportionate to the concerns about the death, and should ensure immediate ‘make safes’ are put in place with all learning shared across the organisation in the usual way.

During the pandemic (February 2020 to Mach 2022) the Live All Wales ICNeT Infection Prevention System had 4 ½ hours scheduled and 2 ½ hours

unscheduled downtime. There have also been times where the database system was available for reporting purposes, however some aspects of the data were temporally not accessible. This amounted to 10 hours during the same time period. A full root cause analysis has been undertaken and corrective actions have been put in place.

With regard to monitoring implementation of the NHS Wales national framework – Management of patient safety incidents following nosocomial transmission of COVID-19, I can confirm this will be part of the assurance work undertaken by the NHS Wales Delivery Unit (DU). Welsh Government will receive regular progress reports from the DU.

Health boards will report progress through their Quality and Safety Committees. This progress will be published on health board websites.