• Trust HSMR has risen over the past 18 months
  • Coding changes expected to reduce mortality rate to normal levels
  • Medway FT was one of the original 14 “Keogh trusts”

A review of deaths at a trust with elevated mortality rates has suggested coding issues, and not care quality, as the likely cause, HSJ has been told.

Medway Foundation Trust’s hospital standardised mortality ratio has risen from around 103 in July 2017 to 116.6 last November. The trust believes this is due to coding issues linked to end of life patients and, once these are addressed, its figure should drop to 102.

The trust’s latest summary hospital-level mortality indicator rate – an alternative measure of mortality – was 110 but the measure only covers the period to September 2018.

Both SHMI and HSMR compared the “expected” numbers of deaths to the actual number, but SHMI also looks at deaths which occur within 30 days of discharge.

Trust chief executive James Devine said: “I don’t think for one moment there is an issue of quality of care going in the wrong direction.”

The trust’s medical director has carried out a mortality review which found “no deficiency” in nursing or medical care, Mr Devine added, and NHS Improvement has seen a summary of the work carried out by the trust and had no issues with it.

The trust was one of the 14 original “Keogh trusts” where higher than average mortality rates sparked a review of the quality of care and treatment in 2013, led by NHS England medical director Sir Bruce Keogh. At that time, the trust had an HSMR of 113 and a SHMI of 109. It was subsequently put into special measures but, after a change of leadership, was taken out of the regime in 2017 and rated “requires improvement” by the Care Quality Commission.

The main diagnostic groups with high mortality rates are stroke, gastrointestinal and elderly medicine, according to Swale Clinical Commissioning Group’s governing body papers.

The trust has enhanced its end of life care team over the last two years, which now sees many patients who would have previously been seen by the palliative care team but not coded in the same way. The trust has agreed with commissioners that this should change and patients who die in the local Wisdom Hospice should no longer be coded as dying in the hospital.

A review with NHS Improvement and consultancy Dr Foster suggested once these changes are implemented, the trust’s HSMR should fall back over time to around 102, said Mr Devine.

The trust’s crude mortality has risen over the last few months – and the number of patients attending its accident and emergency department has increased sharply, including more acutely ill older patients. The trust is currently investigating a high rate of death from pneumonia.

Mr Devine added the trust had been proactive in responding to the mortality rate, rather than being prompted by regulators.