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113 Introducing a learning from deaths meeting in a hospice

Introduction ‘Learning from deaths’ is a monthly meeting open to all clinical staff from across hospice services. It is a forum to discuss, reflect on and learn from the deaths of our patients. Method The meeting was established as there was no formal forum to discuss deaths in the hospice and a positive experience attending a similar event gave the forward momentum and inspiration to create this meeting. Suggestions of deaths to be discussed can be made by any clinician and may include deaths which have been challenging or traumatic as well as deaths which have been examples of good practice. An overview of the case is presented including what happened, what went well and what could be improved. Senior clinicians are present to guide the discussion, ensuring a positive focus is maintained and assisting with identifying the learning for the future. Results This meeting was launched in July 2019. There has been an encouraging turnout with an average of 22 attendees and positive feedback has been given. Particular comment has been made regarding the tone of the meeting and it being a safe, reflective non-judgmental space. Another strength is noted as learning being focused on improving future practice and care. A learning log is gathered during the meetings to ensure that discussion is put into action. For example following one discussion a series of educational sessions were organised about the withdrawal of non-invasive ventilation. Conclusion Learning from deaths is now considered a vital part of clinical practice, support for staff and an opportunity for learning. In the future invitations to attend the meeting could be extended to clinicians from outside the hospice who were involved in the individual’s care e.g. General Practitioners, District Nurses.