Retrospective case note review

Improving quality in acute care through retrospective case record review

To improve our understanding of the scale and causes of in-hospital deaths thought to be due to problems in care, NHS England’s Patient Safety Domain has been working to develop a standardised process for retrospective case record review (RCRR) for adult, in-hospital deaths in England.

RCRR is the process of retrospectively reviewing the care of a patient through an analysis of their care record, usually guided by a series of question and the completion of a review form.


The development of standardised, systematic RCRR is an ambition for many organisations nationally and internationally.

NHS England’s programme builds on work led by research experts in this field, including The London School of Hygiene and Tropical Medicines, to develop a better understanding of in-hospital deaths. This work is in support of Sir Bruce Keogh’s review of mortality rates following publication of the final report of the Mid Staffordshire NHS Foundation Trust Public Inquiry.

Most notably, the programme builds on the methodology developed by Hogan et al in the study Preventable deaths due to problems in care in English acute hospitals: a retrospective case record review study (PRISM 1) and the subsequent study Avoidability of hospital deaths and association with hospital-wide mortality ratios: retrospective case record review and regression analysis (PRISM 2). This research, as set out in the ambitions of The Keogh Mortality Review Outcomes Report, has guided the development of this programme.

Engagement with health providers

The sustainability of this programme depends on engagement at the frontline of hospital-provided care, therefore the main process must be developed and owned locally. Its national rollout will focus on training and supporting the developmental needs required to embed this system within local organisations to empower them with the skills and knowledge to review the care they provide.

Robust data on deaths in hospitals

The Secretary of State for Health asked the NHS Medical Director to examine how to generate and publicise robust data on mortality in hospitals.

As a result, we are examining how we can generate a regular national estimate of the rate of deaths due to problems in care within hospitals in England. Our proposal is that this national estimate will be generated by sampling a representative number of deaths to estimate the rate of those that are due to problems in care. This work is separate to the roll-out of RCRR described above and we anticipate it will be carried out nationally by trained case record reviewers.

Main areas of work

Use the links below to find out about the programme’s main areas of work:

Updates and find out more

Other work areas include research commissioned to understand other levels of harm and harm in different settings that have been commissioned to expand the scope of the RCRR approach to include severe harm (see Developing Methods for Assessing Avoidable Severe Harm Attributable to Problems in Hospital Care). The aspiration is that the method can be used to develop indicators of severe harm thought to be due to problems in care, across the breadth of NHS-funded healthcare, not just in hospitals.