Previous Reference: Minute 23 (2016/17)

The Chief Officer of NHS Airedale, Wharfedale and Craven CCG, NHS Bradford City and NHS Bradford Districts CCG will submit Document “K” which will be supported by a presentation provides the Health and Wellbeing Board with the local picture of how lessons are currently learned from deaths across the health and social care system, the challenges ahead and how the system plans to work together to utilise learning from deaths.  It was prepared at the request of the Board, which, early in 2017, asked for an overview of how learning from deaths takes place in the Bradford and Airedale system.  The presentation, will do the following:

§  Enable key healthcare providers to summarise their own work on developing systems and processes to learn from deaths. 

§  Summarise how providers and commissioners have collaborated to learn from deaths of people with a learning disability

Recommended-

(1)       That the progress already made in response to guidance and commitment to further explore solutions to the challenges be noted.

(2)       That the contribution and commitment which needs to be made by the whole system to learn openly from deaths, to translate learning into improving how care is delivered be considered.

                                                                        (Kate Varley – 01274 256088)

The Chief Officer of NHS Airedale, Wharfedale and Craven CCG, NHS Bradford City and NHS Bradford Districts CCG submitted Document “K” which was supported by a presentation, providing the Health and Wellbeing Board with the local picture of how lessons are currently learned from deaths across the health and social care system, the challenges ahead and how the system planned to work together to utilise learning from deaths.  It was prepared at the request of the Board, which, early in 2017, asked for an overview of how learning from deaths took place in the Bradford and Airedale health and care system.  The presentation, outlined the following:

• Enable key healthcare providers to summarise their own work on developing systems and processes to learn from deaths and,

• Summarise how providers and commissioners have collaborated to learn from deaths of people with a learning disability

In synopsis, the PowerPoint presentation outlined that a total of 4,571 deaths had been registered in Bradford, 2016 which was an increase of around a 100 from the previous year. Bradford had seen the highest number of deaths since 2004 and there were over 150 more deaths per 100,000 population in Bradford in comparison to the national average hence the mortality rates being higher, both regional and on a national basis. Bradford had the highest still birth rate in the region and there had been 55 still births in 2016 compared to 50 in 2015.

A further detailed breakdown of data was covered on the aforementioned, information which had been acquired from Bradford Teaching Hospitals NHS Foundation Trust; Bradford District NHS Foundation Trust; Airedale NHS Foundation Trust; Bradford Metropolitan District Council; NHS Airedale, Wharfedale and Craven CCG; NHS Bradford City CCG; and, NHS Bradford Districts CCG.

During the discussion, the following comments had resulted:

• It was paramount that health and care records accurately reflect the needs of people with learning disabilities, to support their care and subsequent learning by the health and care;
• There were a significant number of people with a learning disability and complex needs in Housing Associations and there was a lack of detailed information on such vulnerable people
• The integration of information sharing between the health and housing sectors would be a significant step for professionals towards learning from deaths across the system;
• Due to the nature of confidentiality, personal information of individuals was not always shared between agencies. Eliminating obstacles to the sharing of data to enable safe high quality care was a key objective for progression towards the Board’s ambition;
• It was important to learn from deaths in order to prevent people from dying prematurely. This would be the ideal overall ambition for the Bradford District;
• A further paramount factor was to have an insight in the everyday living of vulnerable people in communities;
• It would be ideal to pull together the wider determinants of health, data to include information on localities working, information sharing, clarity on safeguarding and to equally have information on people with multiple complex needs;
• Further work is needed to define roles and responsibility of the NHS and Local Authority;
• Analysis needs to take place on how learning disability services are planned, from birth to death;
• West Yorkshire Police are able to provide further information on an individuals death if sudden; and,

Good practice needs to be sought from how community involvement could enhance wellness.

Resolved –

(1)       That the progress already made in response to guidance and commitment to further explore solutions to the challenges be noted.

(2)       That the Deputy Director, Public Health jointly with the Chief       Officer, CCGs to lead work to use General Practice registers of          patient population and learning disabilities, combined with data    sources from partner organisations, to create a more detailed    analysis of the population with learning disabilities, their    access to health and care including annual health checks, and            their health   outcomes compared to the general population and to       other comparable authorities.

LEAD:            Deputy Director, Public Health

                        Chief Officer, CCGs