Level 1 Data and Meeting Booklet10th January 2017

2

Programme 10th January 2016 Mary Ward House, 5-7 Tavistock Square, London WC1H 9SN

Time Topic Speaker/s 1000-1030 Arrival and Coffee 1030-1100 Welcome and Objectives Dr Dale Gardiner

Deputy National CLOD 1100-1215 Best Practice Sharing Session

3 Breakout sessions (rotation through all three groups)

Applying PDSA methods to Referral and SNOD involvement o James Van Der Walt and Hannah Bartlett-Syree Professional Development Team

CLOD Review Recommendations o Dr Dale Gardiner Deputy National CLOD

Promoting Organ Donation o Caroline Rodaway Senior Marketing & Campaigns Officer

1215-1300 Break Out Session 1 1300-1345 Lunch 1345-1410 Improving Organ Utilisation – the role of the

donation community

Dr Paul Murphy National CLOD

1410-1455 Break Out Session 2 1455-1510 Coffee 1510-1555 Break Out Session 3 1555-1600 Summary and Close Dr Paul Murphy

National CLOD

3

Categorisation of Donation Activity by Level

Level 1 12 or more proceeding donors per year (averaged over two years) 33

Level 2 5-12 (> 5 to < 12) proceeding donors per year (averaged over two years) 45

Level 3 3-5 (≥ 3 to ≤ 5) proceeding donors per year (averaged over two years) 47

Level 4 < 3 proceeding donors per year (averaged over two years) 46

For clarity 12 donors = Level 1 5 donors = Level 3 3 donors = Level 3 An additional descriptor is applied to each hospital, as appropriate. N = Adult Neuro ICU (29) P = Paediatric ICU (25) T = Major Trauma Centre (21)

– currently only applies in England pending possible changes in Northern Ireland, Scotland and Wales

Examples Level 1 (NPT), is a hospital Trust / Board that has 12 or more proceeding donors per year and also has a Neuro ICU, is a Major Trauma Centre and has a Paediatric ICU. Level 3 (P), is a hospital Trust / Board that has ≥ 3 to ≤ 5 proceeding donors per year and has a Paediatric ICU.

Trusts or Boards

4!

UK Donation by Level

Level 1 Level 2 Level 3 Level 4

Potential DBD/Eligible DCD donors

Potential donors after brainstem death (DBD) are defined as patients who have neurological death suspected by meeting all of the following criteria: apnoea, coma from known aetiology and unresponsive, ventilated, fixed pupils. Excluding those for whom cardiac arrest occurred despite resuscitation, brain stem reflexes returned. Eligible donors after circulatory death (DCD) are defined as patients who had treatment withdrawn and death was anticipated within four hours, with no absolute medical contraindications to solid organ donation.

Actual Donors

1st October 2015 – 30th September 2016 !

1st October 2015 – 30th September 2016 !

Level 1Level 2Level 3Level 4

Level 1

Level 2

Level 3

Level 4

2674(46%)

1527(26%)

1103(19%)

552(9%)

749(54%)

343(25%)

213(15%)

83(6%)

4!

UK Donation by Level

Level 1 Level 2 Level 3 Level 4

Potential DBD/Eligible DCD donors

Potential donors after brainstem death (DBD) are defined as patients who have neurological death suspected by meeting all of the following criteria: apnoea, coma from known aetiology and unresponsive, ventilated, fixed pupils. Excluding those for whom cardiac arrest occurred despite resuscitation, brain stem reflexes returned. Eligible donors after circulatory death (DCD) are defined as patients who had treatment withdrawn and death was anticipated within four hours, with no absolute medical contraindications to solid organ donation.

Actual Donors

1st October 2015 – 30th September 2016 !

1st October 2015 – 30th September 2016 !

Level 1Level 2Level 3Level 4

Level 1

Level 2

Level 3

Level 4

2674(46%)

1527(26%)

1103(19%)

552(9%)

749(54%)

343(25%)

213(15%)

83(6%)

UK Donation by Level

4!

UK Donation by Level

Level 1 Level 2 Level 3 Level 4

Potential DBD/Eligible DCD donors

Potential donors after brainstem death (DBD) are defined as patients who have neurological death suspected by meeting all of the following criteria: apnoea, coma from known aetiology and unresponsive, ventilated, fixed pupils. Excluding those for whom cardiac arrest occurred despite resuscitation, brain stem reflexes returned. Eligible donors after circulatory death (DCD) are defined as patients who had treatment withdrawn and death was anticipated within four hours, with no absolute medical contraindications to solid organ donation.

Actual Donors

1st October 2015 – 30th September 2016 !

1st October 2015 – 30th September 2016 !

Level 1Level 2Level 3Level 4

Level 1

Level 2

Level 3

Level 4

2674(46%)

1527(26%)

1103(19%)

552(9%)

749(54%)

343(25%)

213(15%)

83(6%)

(19%)

(6%)

(25%)

(49%) 1348(49%)

685(25%)

518(19%)

173(6%)

Potential DBD/Eligible DCD donors1st October 2015 – 30th September 2016

(17%)

(6%)

(21%)

(53%)

689(53%)275

(21%)

223(17%)

103(8%)

Actual donors1st October 2015 – 30th September 2016

Level 1 Level 2 Level 3 Level 4

Potential DBD/Eligible DCD donors

Actual donors

5

Level 1 Group actual deceased donors1st October 2006 – 30th September 2016

52 53 54 53

48

5153 52

55 54

Oct 06 - Sep 07

Oct 07 - Sep 08

Oct 08 - Sep 09

Oct 09 - Sep 10

Oct 10 - Sep 11

Oct 11 - Sep 12

Oct 12 - Sep 13

Oct 13 - Sep 14

Oct 14 - Sep 15

Oct 15 - Sep 16

Year

0

100

200

300

400

500

600

700

800

900

1000

Num

ber

0

10

20

30

40

50

60

%co

ntrib

utio

nto

UKdo

nors

DCDDBD

303

104

310

145

305

186

334

196

321

190

343

232

413

280

422

251

422

291

445

304

Level 1 Group actual deceased donors by Trust/Board 1st October 2015 – 30th September 2016

12

34

56

78

910

1112

1314

1516

1718

1920

2122

2324

2526

2728

2930

3132

33

Trust/Board

0

10

20

30

40

Num

ber

DCDDBD

14

6 32

5

18

6

11

11

14

18

15

9

9

6

5

7

11

10

21

9

5

418

5

2

1017

10

8

19

6

16

14

7

16

19

17

9

15

5

17

12

9

7

13

528

11

18

15

9

9

15

1

17

8

21

8

8

9

7

6

8

5

7

17

5

Level 1 Group actual deceased donors1st October 2006 – 30th September 2016

52 53 54 53

48

5153 52

55 54

Oct 06 - Sep 07

Oct 07 - Sep 08

Oct 08 - Sep 09

Oct 09 - Sep 10

Oct 10 - Sep 11

Oct 11 - Sep 12

Oct 12 - Sep 13

Oct 13 - Sep 14

Oct 14 - Sep 15

Oct 15 - Sep 16

Year

0

100

200

300

400

500

600

700

800

900

1000

Num

ber

0

10

20

30

40

50

60

%co

ntrib

utio

nto

UKdo

nors

DCDDBD

303

104

310

145

305

186

334

196

321

190

343

232

413

280

422

251

422

291

445

304

Level 1 Group actual deceased donors by Trust/Board 1st October 2015 – 30th September 2016

12

34

56

78

910

1112

1314

1516

1718

1920

2122

2324

2526

2728

2930

3132

33

Trust/Board

0

10

20

30

40

Num

ber

DCDDBD

14

6 32

5

18

6

11

11

14

18

15

9

9

6

5

7

11

10

21

9

5

418

5

2

1017

10

8

19

6

16

14

7

16

19

17

9

15

5

17

12

9

7

13

528

11

18

15

9

9

15

1

17

8

21

8

8

9

7

6

8

5

7

17

5

Level 1 Group actual deceased donors1st October 2006 – 30th September 2016

52 53 54 53

48

5153 52

55 54

Oct 06 - Sep 07

Oct 07 - Sep 08

Oct 08 - Sep 09

Oct 09 - Sep 10

Oct 10 - Sep 11

Oct 11 - Sep 12

Oct 12 - Sep 13

Oct 13 - Sep 14

Oct 14 - Sep 15

Oct 15 - Sep 16

Year

0

100

200

300

400

500

600

700

800

900

1000

Num

ber

0

10

20

30

40

50

60

%co

ntrib

utio

nto

UKdo

nors

DCDDBD

303

104

310

145

305

186

334

196

321

190

343

232

413

280

422

251

422

291

445

304

Level 1 Group actual deceased donors by Trust/Board 1st October 2015 – 30th September 2016

12

34

56

78

910

1112

1314

1516

1718

1920

2122

2324

2526

2728

2930

3132

33

Trust/Board

0

10

20

30

40

Num

ber

DCDDBD

14

6 32

5

18

6

11

11

14

18

15

9

9

6

5

7

11

10

21

9

5

418

5

2

1017

10

8

19

6

16

14

7

16

19

17

9

15

5

17

12

9

7

13

528

11

18

15

9

9

15

1

17

8

21

8

8

9

7

6

8

5

7

17

5

Level 1 Group actual deceased donors1st October 2006 – 30th September 2016

52 53 54 53

48

5153 52

55 54

Oct 06 - Sep 07

Oct 07 - Sep 08

Oct 08 - Sep 09

Oct 09 - Sep 10

Oct 10 - Sep 11

Oct 11 - Sep 12

Oct 12 - Sep 13

Oct 13 - Sep 14

Oct 14 - Sep 15

Oct 15 - Sep 16

Year

0

100

200

300

400

500

600

700

800

900

1000

Num

ber

0

10

20

30

40

50

60

%co

ntrib

utio

nto

UKdo

nors

DCDDBD

303

104

310

145

305

186

334

196

321

190

343

232

413

280

422

251

422

291

445

304

Level 1 Group actual deceased donors by Trust/Board 1st October 2015 – 30th September 2016

12

34

56

78

910

1112

1314

1516

1718

1920

2122

2324

2526

2728

2930

3132

33

Trust/Board

0

10

20

30

40

Num

ber

DCDDBD

14

6 32

5

18

6

11

11

14

18

15

9

9

6

5

7

11

10

21

9

5

418

5

2

1017

10

8

19

6

16

14

7

16

19

17

9

15

5

17

12

9

7

13

528

11

18

15

9

9

15

1

17

8

21

8

8

9

7

6

8

5

7

17

5

6

Level 1s neurological death testing rate1st October 2015 – 30th September 2016

● Trust/Board - - - National rate

Greater than 99.8% CL

Between upper 95% CL and upper 99.8% CL

Between lower 95% CL and upper 95% CL

Between lower 99.8% CL and lower 95 % CL

Less than 99.8% CL

Neu

rolo

gica

ldea

thte

stin

gra

te(%

)

0

20

40

60

80

100

Number of neurological death suspected patients0 10 20 30 40 50 60 70

1

10

11

12

13

14

15

16

17

18

19

2

20

21

22

23

24

2526

27

28

29

3

30

31

32

33

4

5

67

8

9----------------------------------------------------------------------•

•

•

•

•

••

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

••

•

•

•

•

•

•

•

7

Level 1s DBD referral rate1st October 2015 – 30th September 2016

● Trust/Board - - - National rate

Greater than 99.8% CL

Between upper 95% CL and upper 99.8% CL

Between lower 95% CL and upper 95% CL

Between lower 99.8% CL and lower 95 % CL

Less than 99.8% CL

Ref

erra

lrat

e(%

)

0

20

40

60

80

100

Number of neurological death suspected patients0 10 20 30 40 50 60 70

11011 12

13 14

15

1617

18

19 220 212223

24

2526 2728 29

330

31

32334

5678

9----------------------------------------------------------------------••

•

•

••••

• •• •

• •

•

••

•

•• •••

•

•• •• •

•

•

••

Level 1s DBD SNOD involvement rate1st October 2015 – 30th September 2016

● Trust/Board - - - National rate

Greater than 99.8% CL

Between upper 95% CL and upper 99.8% CL

Between lower 95% CL and upper 95% CL

Between lower 99.8% CL and lower 95 % CL

Less than 99.8% CL

SN

-OD

invo

lvem

ent(

%)

0

20

40

60

80

100

Number of families approached0 10 20 30 40 50

1

10

11

12

13

14

15

16

1718

19

220

21

22

2324

252627

28

29

330

31

32

33

4

5

67

8

9--------------------------------------------------•

••

•

•

••

•

••

•

•

•

•

•

•

••

•

•

•

•

••

•••

•

•

•

•

•

•

7

Level 1s DBD referral rate1st October 2015 – 30th September 2016

● Trust/Board - - - National rate

Greater than 99.8% CL

Between upper 95% CL and upper 99.8% CL

Between lower 95% CL and upper 95% CL

Between lower 99.8% CL and lower 95 % CL

Less than 99.8% CL

Ref

erra

lrat

e(%

)

0

20

40

60

80

100

Number of neurological death suspected patients0 10 20 30 40 50 60 70

11011 12

13 14

15

1617

18

19 220 212223

24

2526 2728 29

330

31

32334

5678

9----------------------------------------------------------------------••

•

•

••••

• •• •

• •

•

••

•

•• •••

•

•• •• •

•

•

••

Level 1s DBD SNOD involvement rate1st October 2015 – 30th September 2016

● Trust/Board - - - National rate

Greater than 99.8% CL

Between upper 95% CL and upper 99.8% CL

Between lower 95% CL and upper 95% CL

Between lower 99.8% CL and lower 95 % CL

Less than 99.8% CL

SN

-OD

invo

lvem

ent(

%)

0

20

40

60

80

100

Number of families approached0 10 20 30 40 50

1

10

11

12

13

14

15

16

1718

19

220

21

22

2324

252627

28

29

330

31

32

33

4

5

67

8

9--------------------------------------------------•

••

•

•

••

•

••

•

•

•

•

•

•

••

•

•

•

•

••

•••

•

•

•

•

•

•

7

8

Level 1s DBD SNOD involvement rate comparison1st October 2014 – 30th September 2016

● Significant increase at the 5% level

● Significant increase at the 10% level

● Significant decrease at the 5% level

● Significant decrease at the 10% level

32

0 10 20 30 40 50 60 70 80 90 100

Previous Oct-Sep

0

10

20

30

40

50

60

70

80

90

100

Cur

rent

Oct

-Sep

Level 1s DBD consent/authorisation rate1st October 2015 – 30th September 2016

● Trust/Board - - - National rate

Greater than 99.8% CL

Between upper 95% CL and upper 99.8% CL

Between lower 95% CL and upper 95% CL

Between lower 99.8% CL and lower 95 % CL

Less than 99.8% CL

Con

sent

/Aut

horis

atio

nra

te(%

)

0

20

40

60

80

100

Number of families approached0 10 20 30 40 50

1

10

11

12

13

14

15

1617

18

19

220

2122

23

24

252627

28

293

30

31

32

33

4

5 6

7

8

9

--------------------------------------------------

•

••

•

• •

•

•

• •

•

•

•

•

•

••

•

•

•

••

•

•

•••

•

•

•

•

•

•

8

Level 1s DBD SNOD involvement rate comparison1st October 2014 – 30th September 2016

● Significant increase at the 5% level

● Significant increase at the 10% level

● Significant decrease at the 5% level

● Significant decrease at the 10% level

32

0 10 20 30 40 50 60 70 80 90 100

Previous Oct-Sep

0

10

20

30

40

50

60

70

80

90

100

Cur

rent

Oct

-Sep

Level 1s DBD consent/authorisation rate1st October 2015 – 30th September 2016

● Trust/Board - - - National rate

Greater than 99.8% CL

Between upper 95% CL and upper 99.8% CL

Between lower 95% CL and upper 95% CL

Between lower 99.8% CL and lower 95 % CL

Less than 99.8% CL

Con

sent

/Aut

horis

atio

nra

te(%

)

0

20

40

60

80

100

Number of families approached0 10 20 30 40 50

1

10

11

12

13

14

15

1617

18

19

220

2122

23

24

252627

28

293

30

31

32

33

4

5 6

7

8

9

--------------------------------------------------

•

••

•

• •

•

•

• •

•

•

•

•

•

••

•

•

•

••

•

•

•••

•

•

•

•

•

•

9

Level 1s DBD consent/authorisation rate comparison1st October 2015 – 30th September 2016

● Significant increase at the 5% level

● Significant increase at the 10% level

● Significant decrease at the 5% level

● Significant decrease at the 10% level

2

0 10 20 30 40 50 60 70 80 90 100

Previous Oct-Sep

0

10

20

30

40

50

60

70

80

90

100

Cur

rent

Oct

-Sep

Level 1s DBD conversion rate1st October 2015 – 30th September 2016

● Trust/Board - - - National rate

Greater than 99.8% CL

Between upper 95% CL and upper 99.8% CL

Between lower 95% CL and upper 95% CL

Between lower 99.8% CL and lower 95 % CL

Less than 99.8% CL

Con

vers

ion

rate

(%)

0

20

40

60

80

100

Number of eligible DBD0 10 20 30 40 50 60

110

11

12

13

14

15

16

17

18

19

220

21

22

23

24

25

26

27

28

29

330

31

32

334

5

6

7

8

9

------------------------------------------------------------•

••

•

•

•

•

•

••

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

••

•

•

•

8

10

Level 1s DBD conversion rate comparison1st October 2014 – 30th September 2016

● Significant increase at the 5% level

● Significant increase at the 10% level

● Significant decrease at the 5% level

● Significant decrease at the 10% level

2

0 10 20 30 40 50 60 70 80 90 100

Previous Oct-Sep

0

10

20

30

40

50

60

70

80

90

100

Cur

rent

Oct

-Sep

9

Level 1s DBD consent/authorisation rate comparison1st October 2015 – 30th September 2016

● Significant increase at the 5% level

● Significant increase at the 10% level

● Significant decrease at the 5% level

● Significant decrease at the 10% level

2

0 10 20 30 40 50 60 70 80 90 100

Previous Oct-Sep

0

10

20

30

40

50

60

70

80

90

100

Cur

rent

Oct

-Sep

Level 1s DBD conversion rate1st October 2015 – 30th September 2016

● Trust/Board - - - National rate

Greater than 99.8% CL

Between upper 95% CL and upper 99.8% CL

Between lower 95% CL and upper 95% CL

Between lower 99.8% CL and lower 95 % CL

Less than 99.8% CL

Con

vers

ion

rate

(%)

0

20

40

60

80

100

Number of eligible DBD0 10 20 30 40 50 60

110

11

12

13

14

15

16

17

18

19

220

21

22

23

24

25

26

27

28

29

330

31

32

334

5

6

7

8

9

------------------------------------------------------------•

••

•

•

•

•

•

••

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

•

••

•

•

•

9

11

Level 1s DCD referral rate1st October 2015 – 30th September 2016

● Trust/Board - - - National rate

Greater than 99.8% CL

Between upper 95% CL and upper 99.8% CL

Between lower 95% CL and upper 95% CL

Between lower 99.8% CL and lower 95 % CL

Less than 99.8% CL

Ref

erra

lrat

e(%

)

0

20

40

60

80

100

Number of imminent death anticipated patients0 20 40 60 80 100 120 140 160 180

1

1011 12

13

14

15

1617

18

19

220

21 2223

24

2526

27

28

293

30

3132 334 5

67

8

9------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------•

••

• •

••

•

•

•• •

•

•

•

• •

•

•

•

• ••

•

••

•

•

•

•

••

•

Level 1s DCD referral rate comparison1st October 2014 – 30th September 2016

● Significant increase at the 5% level

● Significant increase at the 10% level

● Significant decrease at the 5% level

● Significant decrease at the 10% level

4

712

15

19

20

25

293233

0 10 20 30 40 50 60 70 80 90 100

Previous Oct-Sep

0

10

20

30

40

50

60

70

80

90

100

Cur

rent

Oct

-Sep

10

12

Level 1s DCD SNOD involvement rate1st October 2014 – 30th September 2016

● Trust/Board - - - National rate

Greater than 99.8% CL

Between upper 95% CL and upper 99.8% CL

Between lower 95% CL and upper 95% CL

Between lower 99.8% CL and lower 95 % CL

Less than 99.8% CL

SN

-OD

invo

lvem

ent(

%)

0

20

40

60

80

100

Number of families approached0 10 20 30 40 50 60 70

1

10

1112

13

14

151617

18

19

2

2021

22

23

24

25

2627

28

29

3

30

31

32

33

4

5

6

7

89

----------------------------------------------------------------------•

•

•

•

•

•

•

••

•

••

•

•

•••

•

•

••

•

•

•

•

••

•

••

•

•

•

Level 1s DCD SNOD involvement rate comparison1st October 2014 – 30th September 2016

● Significant increase at the 5% level

● Significant increase at the 10% level

● Significant decrease at the 5% level

● Significant decrease at the 10% level

14

1533

0 10 20 30 40 50 60 70 80 90 100

Previous Oct-Sep

0

10

20

30

40

50

60

70

80

90

100

Cur

rent

Oct

-Sep

11

13

Level 1s DCD consent/authorisation rate1st October 2015 – 30th September 2016

● Trust/Board - - - National rate

Greater than 99.8% CL

Between upper 95% CL and upper 99.8% CL

Between lower 95% CL and upper 95% CL

Between lower 99.8% CL and lower 95 % CL

Less than 99.8% CL

Con

sent

/Aut

horis

atio

nra

te(%

)

0

20

40

60

80

100

Number of families approached0 10 20 30 40 50 60 70

110

11 12

13

14

15

16

17

18

19

220

21

22

23

24

2526

27

28

293

3031

32

33

4

56

7

8

9

----------------------------------------------------------------------•

••

•

••

•

•

•

•

• •

•

•

•

•

•

•

•

•

•

•

•

•

••

•

•

•

• •

•

•

Level 1s DCD consent/authorisation rate comparison1st October 2014 – 30th September 2016

● Significant increase at the 5% level

● Significant increase at the 10% level

● Significant decrease at the 5% level

● Significant decrease at the 10% level

13

15

0 10 20 30 40 50 60 70 80 90 100

Previous Oct-Sep

0

10

20

30

40

50

60

70

80

90

100

Cur

rent

Oct

-Sep

12

14

Level 1s DCD conversion rate1st October 2015 – 30th September 2016

● Trust/Board - - - National rate

Greater than 99.8% CL

Between upper 95% CL and upper 99.8% CL

Between lower 95% CL and upper 95% CL

Between lower 99.8% CL and lower 95 % CL

Less than 99.8% CL

Con

vers

ion

rate

(%)

0

20

40

60

80

100

Number of eligible DCD0 20 40 60 80 100 120

1 10

1112

1314

15

16

1718

192

20

21

22

23

24

25

26

27

2829

33031

32

334 5

6

7 8 9

------------------------------------------------------------------------------------------------------------------------•

• •

• •

•

• • • •

••

••

•

•

••

•

•

•

•

•

•

•

•

•

••

•••

•

Next 4 pages – 1 table per page – rotated 90 degrees as in Level 2 booklet Level 1: tabulated rates: All Level 1: tabulated rates: highlighting gold and silver Level 1: tabulated rates: highlighting bronze Level 1: tabulated rates: highlighting amber and red Please add under each table: N = denominator (number of opportunities available) e.g. Norfolk and Norwich DBD Consent Rate is 66.7% (9) as on 6 out of 9 occasions possible consent was given.

13

14

Leve

l 1

1 O

ctob

er 2

015

- 30

Sept

embe

r 201

6

Trus

t/boa

rd

Neu

rolo

gica

l de

ath

test

ing

rate

% (N

)D

BD

refe

rral

rate

%

(N)

% o

f DB

D

appr

oach

es

whe

re S

NO

D

invo

lved

% (N

)

DB

D c

onse

nt/

auth

oris

atio

n ra

te %

(N)

DC

D re

ferr

al ra

te

% (N

)

% o

f DC

D

appr

oach

es

whe

re S

NO

D

invo

lved

% (N

)

DC

D c

onse

nt/

auth

oris

atio

n ra

te %

(N)

Bar

king

, Hav

erin

g an

d R

edbr

idge

Uni

vers

ity H

ospi

tals

NH

S T

rust

89.7

(39)

94.9

(39)

100

(30)

46.7

(30)

96.2

(52)

80 (1

5)53

.3 (1

5)B

arts

Hea

lth N

HS

Tru

st85

.1 (6

7)97

(67)

98 (5

0)68

(50)

84.9

(73)

88 (2

5)60

(25)

Bel

fast

Hea

lth a

nd S

ocia

l Car

e Tr

ust

80 (4

0)95

(40)

96.6

(29)

72.4

(29)

82.8

(99)

80 (2

5)56

(25)

Brig

hton

and

Sus

sex

Uni

vers

ity H

ospi

tals

NH

S T

rust

58.6

(29)

89.7

(29)

57.1

(14)

85.7

(14)

77.8

(72)

63.6

(33)

66.7

(33)

Cam

brid

ge U

nive

rsity

Hos

pita

ls N

HS

Fou

ndat

ion

Trus

t70

.6 (3

4)97

.1 (3

4)86

.4 (2

2)63

.6 (2

2)78

.3 (1

6174

(50)

56 (5

0)C

ardi

ff A

nd V

ale

Hea

lth B

oard

88.5

(26)

100

(26)

95.7

(23)

65.2

(23)

93.5

(107

87.8

(41)

53.7

(41)

Frim

ley

Hea

lth N

HS

Fou

ndat

ion

Trus

t85

.7 (2

1)10

0 (2

1)10

0 (1

6)56

.3 (1

6)96

(50)

100

(15)

73.3

(15)

Hul

l and

Eas

t Yor

kshi

re H

ospi

tals

NH

S T

rust

77.8

(9)

100

(9)

66.7

(6)

66.7

(6)

79.3

(58)

72.7

(22)

63.6

(22)

Impe

rial C

olle

ge H

ealth

care

NH

S T

rust

83.7

(43)

97.7

(43)

96.6

(29)

58.6

(29)

84.2

(57)

76 (2

5)52

(25)

Kin

g's

Col

lege

Hos

pita

l NH

S F

ound

atio

n Tr

ust

95 (6

0)98

.3 (6

0)93

.2 (4

4)56

.8 (4

4)90

.8 (8

7)10

0 (2

6)57

.7 (2

6)La

ncas

hire

Tea

chin

g H

ospi

tals

NH

S F

ound

atio

n Tr

ust

64.3

(14)

100

(14)

100

(6)

83.3

(6)

93.2

(74)

90.5

(21)

47.6

(21)

Leed

s Te

achi

ng H

ospi

tals

NH

S T

rust

90.6

(32)

100

(32)

92.6

(27)

74.1

(27)

94.2

(171

92.9

(28)

46.4

(28)

NH

S G

ram

pian

72.7

(11)

90.9

(11)

71.4

(7)

42.9

(7)

83.1

(65)

75 (2

8)57

.1 (2

8)N

HS

Gre

ater

Gla

sgow

& C

lyde

83.3

(30)

90 (3

0)95

.5 (2

2)81

.8 (2

2)77

.8 (6

3)56

.8 (3

7)43

.2 (3

7)N

HS

Lot

hian

95 (2

0)80

(20)

60 (1

5)53

.3 (1

5)86

.2 (8

7)78

.3 (4

6)69

.6 (4

6)N

orfo

lk a

nd N

orw

ich

Uni

vers

ity H

ospi

tals

NH

S F

ound

atio

n Tr

ust

100

(9)

100

(9)

66.7

(9)

66.7

(9)

95.2

(62)

80.6

(31)

77.4

(31)

Nor

th B

risto

l NH

S T

rust

88.6

(35)

97.1

(35)

96.3

(27)

70.4

(27)

93.8

(64)

83.9

(31)

64.5

(31)

Not

tingh

am U

nive

rsity

Hos

pita

ls N

HS

Tru

st62

.5 (4

0)90

(40)

91.7

(24)

66.7

(24)

78.3

(143

75 (6

8)54

.4 (6

8)O

xfor

d U

nive

rsity

Hos

pita

ls N

HS

Tru

st90

.2 (4

1)97

.6 (4

1)87

.9 (3

3)57

.6 (3

3)66

.7 (9

3)65

.7 (3

5)45

.7 (3

5)P

lym

outh

Hos

pita

ls N

HS

Tru

st10

0 (2

6)10

0 (2

6)95

.2 (2

1)71

.4 (2

1)81

.6 (3

8)93

.8 (1

6)56

.3 (1

6)S

alfo

rd R

oyal

NH

S F

ound

atio

n Tr

ust

91.9

(37)

100

(37)

100

(33)

57.6

(33)

96.1

(51)

96.6

(29)

65.5

(29)

She

ffiel

d Te

achi

ng H

ospi

tals

NH

S F

ound

atio

n Tr

ust

100

(20)

100

(20)

94.1

(17)

58.8

(17)

95.2

(62)

100

(20)

60 (2

0)S

outh

Tee

s H

ospi

tals

NH

S F

ound

atio

n Tr

ust

93.8

(16)

100

(16)

100

(15)

86.7

(15)

98.7

(79)

80 (2

0)65

(20)

St G

eorg

e's

Hea

lthca

re N

HS

Fou

ndat

ion

Trus

t86

.2 (5

8)94

.8 (5

8)95

.6 (4

5)68

.9 (4

5)93

(71)

91.9

(37)

59.5

(37)

The

New

cast

le U

pon

Tyne

Hos

pita

ls N

HS

Fou

ndat

ion

Trus

t10

0 (4

0)10

0 (4

0)10

0 (3

5)62

.9 (3

5)98

.6 (1

3885

.7 (4

2)69

(42)

The

Wal

ton

Cen

tre N

HS

Fou

ndat

ion

Trus

t10

0 (1

5)10

0 (1

5)10

0 (1

4)64

.3 (1

4)10

0 (3

5)10

0 (1

9)68

.4 (1

9)U

nive

rsity

Col

lege

Lon

don

Hos

pita

ls N

HS

Fou

ndat

ion

Trus

t90

.6 (3

2)10

0 (3

2)96

.2 (2

6)61

.5 (2

6)92

(25)

100

(7)

28.6

(7)

Uni

vers

ity H

ospi

tal S

outh

ampt

on N

HS

Fou

ndat

ion

Trus

t80

(30)

96.7

(30)

90.9

(22)

81.8

(22)

62.1

(87)

80 (2

5)64

(25)

Uni

vers

ity H

ospi

tals

Birm

ingh

am N

HS

Fou

ndat

ion

Trus

t91

.4 (3

5)97

.1 (3

5)85

.7 (2

8)75

(28)

80.4

(97)

70.8

(24)

58.3

(24)

Uni

vers

ity H

ospi

tals

Bris

tol N

HS

Fou

ndat

ion

Trus

t72

.7 (2

2)90

.9 (2

2)92

.3 (1

3)84

.6 (1

3)90

.8 (7

6)75

(28)

50 (2

8)U

nive

rsity

Hos

pita

ls C

oven

try a

nd W

arw

icks

hire

NH

S T

rust

66.7

(12)

100

(12)

57.1

(7)

100

(7)

82.6

(46)

58.6

(29)

51.7

(29)

Uni

vers

ity H

ospi

tals

Of L

eice

ster

NH

S T

rust

83.3

(18)

94.4

(18)

100

(14)

64.3

(14)

80.3

(61)

66.7

(21)

38.1

(21)

Uni

vers

ity H

ospi

tals

Of N

orth

Mid

land

s N

HS

Tru

st64

.3 (1

4)92

.9 (1

4)87

.5 (8

)75

(8)

78.5

(130

75 (4

4)59

.1 (4

4)

N =

den

omin

ator

(num

ber o

f opp

ortu

nitie

s av

aila

ble)

e.g.

Nor

folk

and

Nor

wic

h D

BD

Con

sent

Rat

e is

66.

7% (9

) as

on 6

out

of 9

occ

asio

ns c

onse

nt w

as g

iven

.

Leve

l 1: T

abul

ated

rate

s: A

ll1st

Oct

ober

201

5 –

30th S

epte

mbe

r 201

6

15

Leve

l 1 (

gold

and

silv

er)

Trus

t/boa

rd

1 O

ctob

er 2

015

- 30

Sept

embe

r 201

6

Neu

rolo

gica

l de

ath

test

ing

rate

% (N

)D

BD

refe

rral

rate

%

(N)

% o

f DB

D

appr

oach

es

whe

re S

NO

D

invo

lved

% (N

)

DB

D

cons

ent/a

utho

risat

ion

rate

% (N

)D

CD

refe

rral

rate

%

(N)

% o

f DC

D

appr

oach

es

whe

re S

NO

D

invo

lved

% (N

)

DC

D

cons

ent/a

utho

risat

ion

rate

% (N

)B

arki

ng, H

aver

ing

and

Red

brid

ge U

nive

rsity

Hos

pita

ls N

HS

Tru

st89

.7 (3

9)94

.9 (3

9)10

0 (3

0)46

.7 (3

0)96

.2 (5

2)80

(15)

53.3

(15)

Bar

ts H

ealth

NH

S T

rust

85.1

(67)

97 (6

7)98

(50)

68 (5

0)84

.9 (7

3)88

(25)

60 (2

5)B

elfa

st H

ealth

and

Soc

ial C

are

Trus

t80

(40)

95 (4

0)96

.6 (2

9)72

.4 (2

9)82

.8 (9

9)80

(25)

56 (2

5)B

right

on a

nd S

usse

x U

nive

rsity

Hos

pita

ls N

HS

Tru

st58

.6 (2

9)89

.7 (2

9)57

.1 (1

4)85

.7 (1

4)77

.8 (7

2)63

.6 (3

3)66

.7 (3

3)C

ambr

idge

Uni

vers

ity H

ospi

tals

NH

S F

ound

atio

n Tr

ust

70.6

(34)

97.1

(34)

86.4

(22)

63.6

(22)

78.3

(161

74 (5

0)56

(50)

Car

diff

And

Val

e H

ealth

Boa

rd88

.5 (2

6)10

0 (2

6)95

.7 (2

3)65

.2 (2

3)93

.5 (1

0787

.8 (4

1)53

.7 (4

1)Fr

imle

y H

ealth

NH

S F

ound

atio

n Tr

ust

85.7

(21)

100

(21)

100

(16)

56.3

(16)

96 (5

0)10

0 (1

5)73

.3 (1

5)H

ull a

nd E

ast Y

orks

hire

Hos

pita

ls N

HS

Tru

st77

.8 (9

)10

0 (9

)66

.7 (6

)66

.7 (6

)79

.3 (5

8)72

.7 (2

2)63

.6 (2

2)Im

peria

l Col

lege

Hea

lthca

re N

HS

Tru

st83

.7 (4

3)97

.7 (4

3)96

.6 (2

9)58

.6 (2

9)84

.2 (5

7)76

(25)

52 (2

5)K

ing'

s C

olle

ge H

ospi

tal N

HS

Fou

ndat

ion

Trus

t95

(60)

98.3

(60)

93.2

(44)

56.8

(44)

90.8

(87)

100

(26)

57.7

(26)

Lanc

ashi

re T

each

ing

Hos

pita

ls N

HS

Fou

ndat

ion

Trus

t64

.3 (1

4)10

0 (1

4)10

0 (6

)83

.3 (6

)93

.2 (7

4)90

.5 (2

1)47

.6 (2

1)Le

eds

Teac

hing

Hos

pita

ls N

HS

Tru

st90

.6 (3

2)10

0 (3

2)92

.6 (2

7)74

.1 (2

7)94

.2 (1

7192

.9 (2

8)46

.4 (2

8)N

HS

Gra

mpi

an72

.7 (1

1)90

.9 (1

1)71

.4 (7

)42

.9 (7

)83

.1 (6

5)75

(28)

57.1

(28)

NH

S G

reat

er G

lasg

ow &

Cly

de83

.3 (3

0)90

(30)

95.5

(22)

81.8

(22)

77.8

(63)

56.8

(37)

43.2

(37)

NH

S L

othi

an95

(20)

80 (2

0)60

(15)

53.3

(15)

86.2

(87)

78.3

(46)

69.6

(46)

Nor

folk

and

Nor

wic

h U

nive

rsity

Hos

pita

ls N

HS

Fou

ndat

ion

Trus

t10

0 (9

)10

0 (9

)66

.7 (9

)66

.7 (9

)95

.2 (6

2)80

.6 (3

1)77

.4 (3

1)N

orth

Bris

tol N

HS

Tru

st88

.6 (3

5)97

.1 (3

5)96

.3 (2

7)70

.4 (2

7)93

.8 (6

4)83

.9 (3

1)64

.5 (3

1)N

ottin

gham

Uni

vers

ity H

ospi

tals

NH

S T

rust

62.5

(40)

90 (4

0)91

.7 (2

4)66

.7 (2

4)78

.3 (1

4375

(68)

54.4

(68)

Oxf

ord

Uni

vers

ity H

ospi

tals

NH

S T

rust

90.2

(41)

97.6

(41)

87.9

(33)

57.6

(33)

66.7

(93)

65.7

(35)

45.7

(35)

Ply

mou

th H

ospi

tals

NH

S T

rust

100

(26)

100

(26)

95.2

(21)

71.4

(21)

81.6

(38)

93.8

(16)

56.3

(16)

Sal

ford

Roy

al N

HS

Fou

ndat

ion

Trus

t91

.9 (3

7)10

0 (3

7)10

0 (3

3)57

.6 (3

3)96

.1 (5

1)96

.6 (2

9)65

.5 (2

9)S

heffi

eld

Teac

hing

Hos

pita

ls N

HS

Fou

ndat

ion

Trus

t10

0 (2

0)10

0 (2

0)94

.1 (1

7)58

.8 (1

7)95

.2 (6

2)10

0 (2

0)60

(20)

Sou

th T

ees

Hos

pita

ls N

HS

Fou

ndat

ion

Trus

t93

.8 (1

6)10

0 (1

6)10

0 (1

5)86

.7 (1

5)98

.7 (7

9)80

(20)

65 (2

0)S

t Geo

rge'

s H

ealth

care

NH

S F

ound

atio

n Tr

ust

86.2

(58)

94.8

(58)

95.6

(45)

68.9

(45)

93 (7

1)91

.9 (3

7)59

.5 (3

7)Th

e N

ewca

stle

Upo

n Ty

ne H

ospi

tals

NH

S F

ound

atio

n Tr

ust

100

(40)

100

(40)

100

(35)

62.9

(35)

98.6

(138

85.7

(42)

69 (4

2)Th

e W

alto

n C

entre

NH

S F

ound

atio

n Tr

ust

100

(15)

100

(15)

100

(14)

64.3

(14)

100

(35)

100

(19)

68.4

(19)

Uni

vers

ity C

olle

ge L

ondo

n H

ospi

tals

NH

S F

ound

atio

n Tr

ust

90.6

(32)

100

(32)

96.2

(26)

61.5

(26)

92 (2

5)10

0 (7

)28

.6 (7

)U

nive

rsity

Hos

pita

l Sou

tham

pton

NH

S F

ound

atio

n Tr

ust

80 (3

0)96

.7 (3

0)90

.9 (2

2)81

.8 (2

2)62

.1 (8

7)80

(25)

64 (2

5)U

nive

rsity

Hos

pita

ls B

irmin

gham

NH

S F

ound

atio

n Tr

ust

91.4

(35)

97.1

(35)

85.7

(28)

75 (2

8)80

.4 (9

7)70

.8 (2

4)58

.3 (2

4)U

nive

rsity

Hos

pita

ls B

risto

l NH

S F

ound

atio

n Tr

ust

72.7

(22)

90.9

(22)

92.3

(13)

84.6

(13)

90.8

(76)

75 (2

8)50

(28)

Uni

vers

ity H

ospi

tals

Cov

entry

and

War

wic

kshi

re N

HS

Tru

st66

.7 (1

2)10

0 (1

2)57

.1 (7

)10

0 (7

)82

.6 (4

6)58

.6 (2

9)51

.7 (2

9)U

nive

rsity

Hos

pita

ls O

f Lei

cest

er N

HS

Tru

st83

.3 (1

8)94

.4 (1

8)10

0 (1

4)64

.3 (1

4)80

.3 (6

1)66

.7 (2

1)38

.1 (2

1)U

nive

rsity

Hos

pita

ls O

f Nor

th M

idla

nds

NH

S T

rust

64.3

(14)

92.9

(14)

87.5

(8)

75 (8

)78

.5 (1

3075

(44)

59.1

(44)

N =

den

omin

ator

(num

ber o

f opp

ortu

nitie

s av

aila

ble)

e.g.

Nor

folk

and

Nor

wic

h D

BD

Con

sent

Rat

e is

66.

7% (9

) as

on 6

out

of 9

occ

asio

ns c

onse

nt w

as g

iven

.

Leve

l 1: T

abul

ated

rate

s: H

ighl

ight

ing

gold

and

silv

er1st

Oct

ober

201

5 –

30th S

epte

mbe

r 201

6

16

Trus

t/boa

rd

Neu

rolo

gica

l de

ath

test

ing

rate

% (N

)D

BD

refe

rral

rate

%

(N)

% o

f DB

D

appr

oach

es

whe

re S

NO

D

invo

lved

% (N

)

DB

D

cons

ent/a

utho

risat

ion

rate

% (N

)D

CD

refe

rral

rate

%

(N)

% o

f DC

D

appr

oach

es

whe

re S

NO

D

invo

lved

% (N

)

DC

D

cons

ent/a

utho

risat

ion

rate

% (N

)B

arki

ng, H

aver

ing

and

Red

brid

ge U

nive

rsity

Hos

pita

ls N

HS

Tru

st89

.7 (3

9)94

.9 (3

9)10

0 (3

0)46

.7 (3

0)96

.2 (5

2)80

(15)

53.3

(15)

Bar

ts H

ealth

NH

S T

rust

85.1

(67)

97 (6

7)98

(50)

68 (5

0)84

.9 (7

3)88

(25)

60 (2

5)B

elfa

st H

ealth

and

Soc

ial C

are

Trus

t80

(40)

95 (4

0)96

.6 (2

9)72

.4 (2

9)82

.8 (9

9)80

(25)

56 (2

5)B

right

on a

nd S

usse

x U

nive

rsity

Hos

pita

ls N

HS

Tru

st58

.6 (2

9)89

.7 (2

9)57

.1 (1

4)85

.7 (1

4)77

.8 (7

2)63

.6 (3

3)66

.7 (3

3)C

ambr

idge

Uni

vers

ity H

ospi

tals

NH

S F

ound

atio

n Tr

ust

70.6

(34)

97.1

(34)

86.4

(22)

63.6

(22)

78.3

(161

74 (5

0)56

(50)

Car

diff

And

Val

e H

ealth

Boa

rd88

.5 (2

6)10

0 (2

6)95

.7 (2

3)65

.2 (2

3)93

.5 (1

0787

.8 (4

1)53

.7 (4

1)Fr

imle

y H

ealth

NH

S F

ound

atio

n Tr

ust

85.7

(21)

100

(21)

100

(16)

56.3

(16)

96 (5

0)10

0 (1

5)73

.3 (1

5)H

ull a

nd E

ast Y

orks

hire

Hos

pita

ls N

HS

Tru

st77

.8 (9

)10

0 (9

)66

.7 (6

)66

.7 (6

)79

.3 (5

8)72

.7 (2

2)63

.6 (2

2)Im

peria

l Col

lege

Hea

lthca

re N

HS

Tru

st83

.7 (4

3)97

.7 (4

3)96

.6 (2

9)58

.6 (2

9)84

.2 (5

7)76

(25)

52 (2

5)K

ing'

s C

olle

ge H

ospi

tal N

HS

Fou

ndat

ion

Trus

t95

(60)

98.3

(60)

93.2

(44)

56.8

(44)

90.8

(87)

100

(26)

57.7

(26)

Lanc

ashi

re T

each

ing

Hos

pita

ls N

HS

Fou

ndat

ion

Trus

t64

.3 (1

4)10

0 (1

4)10

0 (6

)83

.3 (6

)93

.2 (7

4)90

.5 (2

1)47

.6 (2

1)Le

eds

Teac

hing

Hos

pita

ls N

HS

Tru

st90

.6 (3

2)10

0 (3

2)92

.6 (2

7)74

.1 (2

7)94

.2 (1

7192

.9 (2

8)46

.4 (2

8)N

HS

Gra

mpi

an72

.7 (1

1)90

.9 (1

1)71

.4 (7

)42

.9 (7

)83

.1 (6

5)75

(28)

57.1

(28)

NH

S G

reat

er G

lasg

ow &

Cly

de83

.3 (3

0)90

(30)

95.5

(22)

81.8

(22)

77.8

(63)

56.8

(37)

43.2

(37)

NH

S L

othi

an95

(20)

80 (2

0)60

(15)

53.3

(15)

86.2

(87)

78.3

(46)

69.6

(46)

Nor

folk

and

Nor

wic

h U

nive

rsity

Hos

pita

ls N

HS

Fou

ndat

ion

Trus

t10

0 (9

)10

0 (9

)66

.7 (9

)66

.7 (9

)95

.2 (6

2)80

.6 (3

1)77

.4 (3

1)N

orth

Bris

tol N

HS

Tru

st88

.6 (3

5)97

.1 (3

5)96

.3 (2

7)70

.4 (2

7)93

.8 (6

4)83

.9 (3

1)64

.5 (3

1)N

ottin

gham

Uni

vers

ity H

ospi

tals

NH

S T

rust

62.5

(40)

90 (4

0)91

.7 (2

4)66

.7 (2

4)78

.3 (1

4375

(68)

54.4

(68)

Oxf

ord

Uni

vers

ity H

ospi

tals

NH

S T

rust

90.2

(41)

97.6

(41)

87.9

(33)

57.6

(33)

66.7

(93)

65.7

(35)

45.7

(35)

Ply

mou

th H

ospi

tals

NH

S T

rust

100

(26)

100

(26)

95.2

(21)

71.4

(21)

81.6

(38)

93.8

(16)

56.3

(16)

Sal

ford

Roy

al N

HS

Fou

ndat

ion

Trus

t91

.9 (3

7)10

0 (3

7)10

0 (3

3)57

.6 (3

3)96

.1 (5

1)96

.6 (2

9)65

.5 (2

9)S

heffi

eld

Teac

hing

Hos

pita

ls N

HS

Fou

ndat

ion

Trus

t10

0 (2

0)10

0 (2

0)94

.1 (1

7)58

.8 (1

7)95

.2 (6

2)10

0 (2

0)60

(20)

Sou

th T

ees

Hos

pita

ls N

HS

Fou

ndat

ion

Trus

t93

.8 (1

6)10

0 (1

6)10

0 (1

5)86

.7 (1

5)98

.7 (7

9)80

(20)

65 (2

0)S

t Geo

rge'

s H

ealth

care

NH

S F

ound

atio

n Tr

ust

86.2

(58)

94.8

(58)

95.6

(45)

68.9

(45)

93 (7

1)91

.9 (3

7)59

.5 (3

7)Th

e N

ewca

stle

Upo

n Ty

ne H

ospi

tals

NH

S F

ound

atio

n Tr

ust

100

(40)

100

(40)

100

(35)

62.9

(35)

98.6

(138

85.7

(42)

69 (4

2)Th

e W

alto

n C

entre

NH

S F

ound

atio

n Tr

ust

100

(15)

100

(15)

100

(14)

64.3

(14)

100

(35)

100

(19)

68.4

(19)

Uni

vers

ity C

olle

ge L

ondo

n H

ospi

tals

NH

S F

ound

atio

n Tr

ust

90.6

(32)

100

(32)

96.2

(26)

61.5

(26)

92 (2

5)10

0 (7

)28

.6 (7

)U

nive

rsity

Hos

pita

l Sou

tham

pton

NH

S F

ound

atio

n Tr

ust

80 (3

0)96

.7 (3

0)90

.9 (2

2)81

.8 (2

2)62

.1 (8

7)80

(25)

64 (2

5)U

nive

rsity

Hos

pita

ls B

irmin

gham

NH

S F

ound

atio

n Tr

ust

91.4

(35)

97.1

(35)

85.7

(28)

75 (2

8)80

.4 (9

7)70

.8 (2

4)58

.3 (2

4)U

nive

rsity

Hos

pita

ls B

risto

l NH

S F

ound

atio

n Tr

ust

72.7

(22)

90.9

(22)

92.3

(13)

84.6

(13)

90.8

(76)

75 (2

8)50

(28)

Uni

vers

ity H

ospi

tals

Cov

entry

and

War

wic

kshi

re N

HS

Tru

st66

.7 (1

2)10

0 (1

2)57

.1 (7

)10

0 (7

)82

.6 (4

6)58

.6 (2

9)51

.7 (2

9)U

nive

rsity

Hos

pita

ls O

f Lei

cest

er N

HS

Tru

st83

.3 (1

8)94

.4 (1

8)10

0 (1

4)64

.3 (1

4)80

.3 (6

1)66

.7 (2

1)38

.1 (2

1)U

nive

rsity

Hos

pita

ls O

f Nor

th M

idla

nds

NH

S T

rust

64.3

(14)

92.9

(14)

87.5

(8)

75 (8

)78

.5 (1

3075

(44)

59.1

(44)

N =

den

omin

ator

(num

ber o

f opp

ortu

nitie

s av

aila

ble)

e.g.

Nor

folk

and

Nor

wic

h D

BD

Con

sent

Rat

e is

66.

7% (9

) as

on 6

out

of 9

occ

asio

ns c

onse

nt w

as g

iven

.

Leve

l 1: T

abul

ated

rate

s: H

ighl

ight

ing

bron

ze1st

Oct

ober

201

5 –

30th S

epte

mbe

r 201

6

17

Trus

t/boa

rd

Neu

rolo

gica

l de

ath

test

ing

rate

% (N

)D

BD

refe

rral

rate

%

(N)

% o

f DB

D

appr

oach

es

whe

re S

NO

D

invo

lved

% (N

)

DB

D

cons

ent/a

utho

risat

ion

rate

% (N

)D

CD

refe

rral

rate

%

(N)

% o

f DC

D

appr

oach

es

whe

re S

NO

D

invo

lved

% (N

)

DC

D

cons

ent/a

utho

risat

ion

rate

% (N

)B

arki

ng, H

aver

ing

and

Red

brid

ge U

nive

rsity

Hos

pita

ls N

HS

Tru

st89

.7 (3

9)94

.9 (3

9)10

0 (3

0)46

.7 (3

0)96

.2 (5

2)80

(15)

53.3

(15)

Bar

ts H

ealth

NH

S T

rust

85.1

(67)

97 (6

7)98

(50)

68 (5

0)84

.9 (7

3)88

(25)

60 (2

5)B

elfa

st H

ealth

and

Soc

ial C

are

Trus

t80

(40)

95 (4

0)96

.6 (2

9)72

.4 (2

9)82

.8 (9

9)80

(25)

56 (2

5)B

right

on a

nd S

usse

x U

nive

rsity

Hos

pita

ls N

HS

Tru

st58

.6 (2

9)89

.7 (2

9)57

.1 (1

4)85

.7 (1

4)77

.8 (7

2)63

.6 (3

3)66

.7 (3

3)C

ambr

idge

Uni

vers

ity H

ospi

tals

NH

S F

ound

atio

n Tr

ust

70.6

(34)

97.1

(34)

86.4

(22)

63.6

(22)

78.3

(161

74 (5

0)56

(50)

Car

diff

And

Val

e H

ealth

Boa

rd88

.5 (2

6)10

0 (2

6)95

.7 (2

3)65

.2 (2

3)93

.5 (1

0787

.8 (4

1)53

.7 (4

1)Fr

imle

y H

ealth

NH

S F

ound

atio

n Tr

ust

85.7

(21)

100

(21)

100

(16)

56.3

(16)

96 (5

0)10

0 (1

5)73

.3 (1

5)H

ull a

nd E

ast Y

orks

hire

Hos

pita

ls N

HS

Tru

st77

.8 (9

)10

0 (9

)66

.7 (6

)66

.7 (6

)79

.3 (5

8)72

.7 (2

2)63

.6 (2

2)Im

peria

l Col

lege

Hea

lthca

re N

HS

Tru

st83

.7 (4

3)97

.7 (4

3)96

.6 (2

9)58

.6 (2

9)84

.2 (5

7)76

(25)

52 (2

5)K

ing'

s C

olle

ge H

ospi

tal N

HS

Fou

ndat

ion

Trus

t95

(60)

98.3

(60)

93.2

(44)

56.8

(44)

90.8

(87)

100

(26)

57.7

(26)

Lanc

ashi

re T

each

ing

Hos

pita

ls N

HS

Fou

ndat

ion

Trus

t64

.3 (1

4)10

0 (1

4)10

0 (6

)83

.3 (6

)93

.2 (7

4)90

.5 (2

1)47

.6 (2

1)Le

eds

Teac

hing

Hos

pita

ls N

HS

Tru

st90

.6 (3

2)10

0 (3

2)92

.6 (2

7)74

.1 (2

7)94

.2 (1

7192

.9 (2

8)46

.4 (2

8)N

HS

Gra

mpi

an72

.7 (1

1)90

.9 (1

1)71

.4 (7

)42

.9 (7

)83

.1 (6

5)75

(28)

57.1

(28)

NH

S G

reat

er G

lasg

ow &

Cly

de83

.3 (3

0)90

(30)

95.5

(22)

81.8

(22)

77.8

(63)

56.8

(37)

43.2

(37)

NH

S L

othi

an95

(20)

80 (2

0)60

(15)

53.3

(15)

86.2

(87)

78.3

(46)

69.6

(46)

Nor

folk

and

Nor

wic

h U

nive

rsity

Hos

pita

ls N

HS

Fou

ndat

ion

Trus

t10

0 (9

)10

0 (9

)66

.7 (9

)66

.7 (9

)95

.2 (6

2)80

.6 (3

1)77

.4 (3

1)N

orth

Bris

tol N

HS

Tru

st88

.6 (3

5)97

.1 (3

5)96

.3 (2

7)70

.4 (2

7)93

.8 (6

4)83

.9 (3

1)64

.5 (3

1)N

ottin

gham

Uni

vers

ity H

ospi

tals

NH

S T

rust

62.5

(40)

90 (4

0)91

.7 (2

4)66

.7 (2

4)78

.3 (1

4375

(68)

54.4

(68)

Oxf

ord

Uni

vers

ity H

ospi

tals

NH

S T

rust

90.2

(41)

97.6

(41)

87.9

(33)

57.6

(33)

66.7

(93)

65.7

(35)

45.7

(35)

Ply

mou

th H

ospi

tals

NH

S T

rust

100

(26)

100

(26)

95.2

(21)

71.4

(21)

81.6

(38)

93.8

(16)

56.3

(16)

Sal

ford

Roy

al N

HS

Fou

ndat

ion

Trus

t91

.9 (3

7)10

0 (3

7)10

0 (3

3)57

.6 (3

3)96

.1 (5

1)96

.6 (2

9)65

.5 (2

9)S

heffi

eld

Teac

hing

Hos

pita

ls N

HS

Fou

ndat

ion

Trus

t10

0 (2

0)10

0 (2

0)94

.1 (1

7)58

.8 (1

7)95

.2 (6

2)10

0 (2

0)60

(20)

Sou

th T

ees

Hos

pita

ls N

HS

Fou

ndat

ion

Trus

t93

.8 (1

6)10

0 (1

6)10

0 (1

5)86

.7 (1

5)98

.7 (7

9)80

(20)

65 (2

0)S

t Geo

rge'

s H

ealth

care

NH

S F

ound

atio

n Tr

ust

86.2

(58)

94.8

(58)

95.6

(45)

68.9

(45)

93 (7

1)91

.9 (3

7)59

.5 (3

7)Th

e N

ewca

stle

Upo

n Ty

ne H

ospi

tals

NH

S F

ound

atio

n Tr

ust

100

(40)

100

(40)

100

(35)

62.9

(35)

98.6

(138

85.7

(42)

69 (4

2)Th

e W

alto

n C

entre

NH

S F

ound

atio

n Tr

ust

100

(15)

100

(15)

100

(14)

64.3

(14)

100

(35)

100

(19)

68.4

(19)

Uni

vers

ity C

olle

ge L

ondo

n H

ospi

tals

NH

S F

ound

atio

n Tr

ust

90.6

(32)

100

(32)

96.2

(26)

61.5

(26)

92 (2

5)10

0 (7

)28

.6 (7

)U

nive

rsity

Hos

pita

l Sou

tham

pton

NH

S F

ound

atio

n Tr

ust

80 (3

0)96

.7 (3

0)90

.9 (2

2)81

.8 (2

2)62

.1 (8

7)80

(25)

64 (2

5)U

nive

rsity

Hos

pita

ls B

irmin

gham

NH

S F

ound

atio

n Tr

ust

91.4

(35)

97.1

(35)

85.7

(28)

75 (2

8)80

.4 (9

7)70

.8 (2

4)58

.3 (2

4)U

nive

rsity

Hos

pita

ls B

risto

l NH

S F

ound

atio

n Tr

ust

72.7

(22)

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Comparison of neurological death testing by level 1st October 2015 – 30th September 2016

Comparison of combined DBD and DCD referral by level 1st October 2015 – 30th September 2016

18

16

Comparison of combined DBD and DCD SNOD involvement by level 1st October 2015 – 30th September 2016

Comparison of combined DBD and DCD consent/authorisation by level 1st October 2015 – 30th September 2016

19

17

Applying PDSA methods

Why? Why?Why?

Cycle end date: Cycle start date:

Issue: Cycle number:

Why?

X

Guide to completing your PDSA cycle template

State here your main ‘why’ This should be your root causeNow question your main ‘why’

Explain what your next steps will be now that your first cycle has come to an end. If the cycle was successful: You will have achieved your primary goal. As no further cycles are required make sure you delete any blank slides.If the cycle was not successful: Copy your current cycle, paste the text onto the next template and adapt the plan and do sections accordingly.

What are you trying to achieve?

Explain what you are going to do and why. You will find an example on slide 3. which should help you complete this.

Explain what it is that you actually did. This may differ to what you had initially planned to do.

Note the lessons that you have learnt, addressing any problems that you found and summarising your result.You will find an example on slide 3. which should help you complete this.

What is the issue/problem?

dd/mm/yyyy dd/mm/yyyy

Why? Why?Why?

Cycle end date: Cycle start date:

Issue: Cycle number:Hints & tips to help you complete your PDSA cycle

1. Plan: Be clear about the primary goal you aim to change, the questions that need to be answered and what is expected to happen. Plan how the PDSA cycle will be carried out, specifying who will be responsible for implementing the plan, where and when it will be tested, what will be done and what the expected outcomes might be.

Notes: when running PDSA cycles•Don’t think too big. Implement a small simple change as this is more likely to be successful.•Don’t be too vague or too detailed - some detail is needed but to a practical, not obsessive, level.•Make sure the results are acted on.•In practice more than one PDSA cycle can be run at a time as long as they are small and simple.

2. Do: Carry out the plan and record the agreed measures and outcomes carefully. Ensure that any problems or other unexpected events are also documented.

3. Study: Compare what the outcomes were to what you thought would happen. Ask those who were involved and study what actually happened, noting problems and other unexpected events. Summarise the outcome of the pilot.

4. Act: As a team decide what should happen next? Should the same primary goal be kept but the cycle repeated, should the primary goal be adapted and the cycle run again or should the cycle be stopped. Make the decision based on what was learnt from the PDSA cycle. It is possible that a single PDSA cycle will show a primary goal that can be achieved and be applied more widely or even adopted into routine practice. However, remember that several cycles might have to be run before a primary goal of a PDSA cycle is successfully adopted into normal practice.

To Start: Identify issue to be addressed and drill down using 3 whys to create your primary goal.

Each primary goal should have at least 1 PDSA cycle. Each cycle has 4 sections which are listed below:

20

18

Why? Why?Why?

Cycle end date: Cycle start date:

Issue: Cycle number:

Why?

• More education needed• Use poster board in ED staff room to

promote referral, and feedback results.• Run a 2nd PDSA cycle on this goal

• Engage with ED to identify a local trigger• To highlight with ED Consultants and

Senior Nursing Team• Monitor through the Potential Donor Audit• Review at Organ Donation Committee

(ODC)• Encourage ED attendance at ODC

• Ran PDSA cycle for 1 month• 2 cases of potential donors not referred• Both cases missed at the weekend

• To include Organ Donation trigger as part of End of Life paperwork

• Educate ED medical and nursing teams, cascade message.

50% of missed referrals are in the ED

Not identifying all potential organ donors

100% identification and referral of potential organ donors

No referral trigger in place in ED

1st Sept 2016

70% referral rate 1

21

19

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22

20

Level 1 Group key

Key Trust/Board Key Trust/Board

1Barking, Havering and Redbridge University Hospitals NHS Trust (N) 18 Nottingham University Hospitals NHS Trust (NPT)

2 Barts Health NHS Trust (PT) 19 Oxford University Hospitals NHS Trust (NPT)3 Belfast Health and Social Care Trust (NP) 20 Plymouth Hospitals NHS Trust (NT)4 Brighton and Sussex University Hospitals NHS Trust (NT) 21 Salford Royal NHS Foundation Trust (N)5 Cambridge University Hospitals NHS Foundation Trust (NPT) 22 Sheffield Teaching Hospitals NHS Foundation Trust (NT)6 Cardiff And Vale Health Board (NP) 23 South Tees Hospitals NHS Foundation Trust (NPT)7 Frimley Health NHS Foundation Trust 24 St George's Healthcare NHS Foundation Trust (NPT)

8 Hull and East Yorkshire Hospitals NHS Trust (NT) 25The Newcastle Upon Tyne Hospitals NHS Foundation Trust (NPT)

9 Imperial College Healthcare NHS Trust (NPT) 26 The Walton Centre NHS Foundation Trust (NT)

10 King's College Hospital NHS Foundation Trust (PT) 27University College London Hospitals NHS Foundation Trust (N)

11 Lancashire Teaching Hospitals NHS Foundation Trust (NT) 28University Hospital Southampton NHS Foundation Trust (NPT)

12 Leeds Teaching Hospitals NHS Trust (NPT) 29University Hospitals Birmingham NHS Foundation Trust (NT)

13 NHS Grampian (N) 30 University Hospitals Bristol NHS Foundation Trust (P)

14 NHS Greater Glasgow & Clyde (NP) 31University Hospitals Coventry and Warwickshire NHS Trust (NT)

15 NHS Lothian (NP) 32 University Hospitals Of Leicester NHS Trust (P)16 Norfolk and Norwich University Hospitals NHS Foundation Trust 33 University Hospitals Of North Midlands NHS Trust (NPT)17 North Bristol NHS Trust (NT)

23

Key Trust/Board1 Barking, Havering and Redbridge University Hospitals NHS Trust (N)2 Barts Health NHS Trust (PT)3 Belfast Health and Social Care Trust (NP)4 Brighton and Sussex University Hospitals NHS Trust (NT)5 Cambridge University Hospitals NHS Foundation Trust (NPT)6 Cardiff And Vale Health Board (NP)7 Frimley Health NHS Foundation Trust8 Hull and East Yorkshire Hospitals NHS Trust (NT)9 Imperial College Healthcare NHS Trust (NPT)10 King’s College Hospital NHS Foundation Trust (PT)11 Lancashire Teaching Hospitals NHS Foundation Trust (NT)12 Leeds Teaching Hospitals NHS Trust (NPT)13 NHS Grampian (N)14 NHS Greater Glasgow & Clyde (NP)15 NHS Lothian (NP)16 Norfolk and Norwich University Hospitals NHS Foundation Trust17 North Bristol NHS Trust (NT)18 Nottingham University Hospitals NHS Trust (NPT)19 Oxford University Hospitals NHS Trust (NPT)20 Plymouth Hospitals NHS Trust (NT)21 Salford Royal NHS Foundation Trust (N)22 Sheffield Teaching Hospitals NHS Foundation Trust (NT)23 South Tees Hospitals NHS Foundation Trust (NPT)24 St George’s Healthcare NHS Foundation Trust (NPT)25 The Newcastle Upon Tyne Hospitals NHS Foundation Trust (NPT)26 The Walton Centre NHS Foundation Trust (NT)27 University College London Hospitals NHS Foundation Trust (N)28 University Hospital Southampton NHS Foundation Trust (NPT)29 University Hospitals Birmingham NHS Foundation Trust (NT)30 University Hospitals Bristol NHS Foundation Trust (P)31 University Hospitals Coventry and Warwickshire NHS Trust (NT)32 University Hospitals Of Leicester NHS Trust (P)33 University Hospitals Of North Midlands NHS Trust (NPT)