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Introduction Inpatient deaths among gastroenterology patients are frequently associated with complex pathologies, including advanced malignancy and decompensated chronic liver disease (DLD). While mortality review is central to patient safety, learning derived from Structured Judgement Review (SJR) in UK gastroenterology services remains under-described. We aimed to identify systemic themes in end-of-life care (EOLC) planning to drive departmental quality improvement towards meeting the five Priorities of Care for the Dying Person – One Chance To Get It Right.1Methods In accordance with the NHS ‘Learning from Deaths’ framework, 234 consecutive inpatient deaths were screened between January 2021 and November 2025 in a 20-bedded gastroenterology ward at a District General Hospital in Northwest England. Sixty (60) cases underwent SJR based on predefined criteria (including random sampling or family concerns) by trained reviewers using the Royal College of Physicians (RCP) National Mortality Case Record Review methodology. 2 To mitigate inter-subjective variability, cases graded as poor care or potential for learning were discussed in a Trust-wide Mortality Review Group (MRG) meeting to achieve peer consensus validation. ‘Delayed Escalation Planning’ was defined as the continuation of active medical treatment without a documented ‘Treatment Escalation Plan’ until <48 hours before death. Statistical comparison between cohorts included Chi-squared analysis (with Odds Ratio calculation) and Mann-Whitney U tests.Results Sixty (60) deaths were reviewed. The median age was 57 years (IQR 49–75). Primary diagnoses included: decompensated chronic liver disease (DLD) (50%, n=30), advanced malignancy (27%, n=16), and acute GI bleeding/sepsis (23%, n=14). Opportunities for improvement were identified in 40% of cases. Quantitative analysis (see table 1) revealed:Demographics: The median age in DLD was 53 years (IQR 47–58) versus 62 years (IQR 52–77) in malignancy. This ‘premature mortality’ in liver disease appeared to drive prognostic uncertainty.The ‘Prognosis Gap’: In 50% (30/60) of total cases, clear indicators of poor prognosis were present on admission, yet a ‘Treatment Escalation Plan (TEP)’ was not documented within the first 48 hours. In this cohort, there was delayed identification of either uncertain recovery or of dying.Treatment Escalation Planning Disparity: A distinct gap was observed. 60% (18/30) of DLD deaths involved significant delays in escalation planning compared to 19% (3/16) in malignancy (χ2=7.1, p<0.01). This represents a substantial effect size, with DLD patients having significantly higher odds of delayed planning compared to malignancy (Odds Ratio 6.5, 95% CI 1.6–26.4).In cases with delayed planning, DLD patients waited significantly longer for a TEP decision: median 7 days (IQR 3–14) versus 1.5 days in malignancy (p=0.02).Outcomes: Two DLD patients (7%) received inappropriate CPR attempts during terminal deterioration, compared to zero in the malignancy cohort.Cultural Themes: Qualitative analysis revealed a perception of palliative care as a ‘terminal event’ in DLD rather than a framework to support care alongside potentially life-prolonging interventions. This resulted in a treatment-focused approach continuing until acute terminal deterioration, even in patients with Child-Pugh C status or MELD >30.Quality Improvement ResponseThese findings established baseline data for ongoing QI work. Interventions implemented include:Education: We implemented Specialist Palliative Care Team consultant-led sessions for all gastroenterology clinicians.Process: ‘Escalation Status’ review mandated as a discussion point at the morning ward round huddle.Governance: Findings integrated into Trust-wide MRG workstream to ensure organisational learning.Dissemination: Specific learning shared at Gastroenterology Mortality and Morbidity Governance meetings and themes distributed widely via Trust-wide safety bulletins.Conclusion SJR in gastroenterology identifies a specific, modifiable vulnerability: the delayed transition from potentially life-prolonging treatment to palliative interventions, driven by prognostic uncertainty and cultural perceptions of palliative care especially in DLD patients. DLD patients die 9 years younger than cancer patients yet wait nearly 5 times longer for escalation planning (7 vs 1.5 days, p=0.02), resulting in the continuation of avoidable, burdensome interventions whilst delaying or omitting beneficial palliative interventions and discussions. Targeted education on ‘parallel planning’ and mandated escalation status review aim to close the identified ‘Prognosis Gap.’ Future audit will assess whether these interventions reduce time to escalation planning and facilitate earlier palliative integration in gastroenterology inpatients, including whether the likelihood of discharge to preferred place of death is improved.References One chance to get it right; Leadership alliance for the care of dying people (2014).National mortality case record review programme: structured judgement review guide; Royal College of Physicians (2016).Abstract P90 Table 1Comparison of escalation planning: decompensated liver disease vs malignancyVariableDecompensated CLD (n=30)Malignancy (n=16)P-ValueMedian Age (Years)53 (IQR 47–58)62 (IQR 52–77)-Delayed Planning (>48h)60% (n=18)19% (n=3)<0.01Median Time to Decision7 Days (IQR 3–14)1.5 Days0.02Inappropriate CPR7% (n=2)0%-