Reducing avoidable deaths in hospital

The NHS Institute staff have been working with a number of partners to identify a set of interventions that work to reduce avoidable deaths in UK hospitals. They have learned that such interventions could save up to 10,000 lives per year in England.

Their partners include:

  • Three acute hospitals who worked on the 'move your mortality dot' programme in the former Modernisation Agency
  • Eight hospitals which were field test sites in a dissemination and spread programme sponsored by the Modernisation Agency
  • Walsall hospital, who have been working on reducing mortality since 2001, suported by Professor Sir Brian Jarman, following the first publication of mortality league tables by Dr Foster
  • The Health Foundation, whose four 'Safer Patients Initative' trusts in England, Scotland, Ireland and Wales have been using tools and techniques from the Institute of Healthcare Improvement in the USA to reduce mortality.

The team organised a knowledge exchange day in collaboration with the Health Foundation, where they aimed to harness the learning and knowledge accumulated by all the acute trusts in the UK who are working on reducing mortality. They also commissioned an evaluation from Matrix Research & Consultancy of the partner hospitals which was completed in August 2006: Scoping of interventions to reduce avoidable mortality.

The NHS Institute Team have now developed guides for leaders based on the outputs from the Matrix evaluation and the knowledge exchange day.  They can be downloaded here by clicking on the links:
Chief Executives lead the way
Medical Directors drive improvement

Supporting materials for the guides are also available, particularly the Global Trigger Tool (used to allow a case notes review to be done quickly) and the 2 x 2 Matrix used to categorise deaths and help prioritise interventions to reduce mortality (sometimes referred to as 3 x 2 matrix).

For further information about how to get involved, contact Hugh Rogers at


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