How should a mortality meeting be managed?

  1. A responsible person must be identified to arrange the meeting. This is usually a doctor working in the paediatric service.
  2. Regular meetings are held once or twice a month depending on the number of deaths.
  3. A suitable time and venue is needed. Often lunch times or late afternoons are best.
  4. All staff involved with child care should be invited (nurses, doctors and administrators). Staff must understand that mortality meetings are very important.
  5. A brief summary of each death, giving relevant information, must be prepared before each mortality meeting.
  6. Anything discussed in the meeting must be viewed as confidential. Summary sheets should be destroyed after the meeting.
  7. The meeting should discussed what ‘we’ did incorrectly and how ‘we’ could do better in future. The meeting must never become a ‘witch hunt’. Any disciplinary action must be handled with the person involved privately outside the meeting and never in front of other staff. Without a spirit of mutual support and trust, important details of the child’s management may be withheld. A team approach is needed to solve problems of patient management.
  8. All decisions (causes and modifiable factors) made must be recorded on the mortality sheets (death data capture sheets) at the time of the meeting and not afterwards when important details may be forgotten.
  9. Decisions about actions to be taken must be documented, and progress must be reviewed at the beginning of the next mortality meeting.

Discussions in a mortality meeting must be confidential and carried out in a constructive and non-threatening manner.

Well organised mortality meetings are one of the best ways of improving the standard of health care of children. Mortality meetings are also a very effective way of teaching. They help staff to identify and solve problems and provide a wonderful learning opportunity. They reduce the number of children who die.

Mortality meetings reduce the number of children who die.

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