Context The intervention was done in Glan Clwyd Hospital, Wales, UK. Mortality Review Group (MRG) is involved, and all the staff in the hospital are the target audience.

Issue/Challenge There was no regular Mortality Review and learning from deaths in Glan Clwyd Hospital (YGC). As a result, 408 mortality reviews are to be completed. It was estimated that 12 months were needed to complete those reviews.

Assessment of issue and analysis of its causes

The 5 Whys approach was used to assess the causal factors, and the SWOT analysis was used to identify the size of the challenges and strategic opportunities. The stakeholders were involved in the multidisciplinary team (MDT), and analysis was disseminated using the PowerPoint presentation.

Impact Good robust multidisciplinary team governance process at the Glan Clwyd Hospital to review all adult deaths. All 408 death reviews were completed within eight months. Regular weekly mortality review is in place. Patient care quality and safety are continuously improving. Staff and professionals benefit from improving their reflective learning practices and continuous learning. Collaborative leadership and continued support with motivation are the factors that led to improving and sustaining the process.

Intervention From the intervention undertaking, all adult deaths in YGC are being reviewed without Glan Clwyd Hospital. Shared learning from Deaths: Regular News bulletin published with learning themes, lessons learned and good practices. Collaborative learning across-the-professional boundaries: Acute care and primary care linked together to learn from reflections.

Involvement of stakeholders, such as patients, carers or family members:

Patients are not involved in this project. Medical/Surgical Consultants, Administrative and Primary Care representatives, Head of Nursing (Acute care and primary care), Pharmacy representative, Senior Trainee, and Deputy Medical Director (Chair) were involved.

Key Messages Through collaborative leadership, managers and executives can create an inclusive environment that energises teams, releases creativity, and cultivates a work culture that is both productive and joyful. This approach will make a safe and efficient health care system.

Lessons learnt By providing collaborative leadership, Medical leaders can improve health by get diverse opinions and ideas among teammates to build strategies and solve problems. As a result, employees are more engaged, feel trusted and are more likely to take ownership of their work.

Measurement of improvement The number of pending case reviews used to measure the effectiveness of the improvement. Currently no pending mortality review in Glan Clwyd Hospital. All adult deaths are getting reviewed on time.

Strategy for improvement TOWS Matrix was used for generating strategic options. Terms of Reference (TOR) were created, and Mortality Review Group -a multidisciplinary team- was formed. The strategies used to implement the improvements are the collaborative leadership style and reflective learning practices with open, transparent, honest discussions with feedback.