Abstract
This month's issue concentrates on avoiding death, particularly in children but also in adults who are hospital inpatients. One powerful method has been the use of confidential enquiries, a format introduced in the UK in 1952 with the initiation of the Confidential Enquiry into Maternal Deaths (CEMD). This produced reports every three years, during which maternal deaths have fallen from 1 in 1500 to 1 in 20,000 – to the extent that indirect causes, such as pre-existing serious illness and suicide have become major determinants while direct complications of pregnancy have been reduced dramatically. Much of the decline is related to CEMD which has been used to put targeted initiatives into place, for example better anaesthesia, appropriate use of antibiotics and prophylaxis against thromboembolism. 1
In 1993, a further confidential enquiry was set up – into stillbirths and deaths in infancy, including sudden unexpected death (CESDI/SUDI). Critics of confidential enquiries complain that their very nature conspires against the transparency nowadays regarded as a mainstay of trust between patients and healthcare providers. But there can be no doubt that protecting the identity of the mothers and children involved, as well as the staff and the institutions reporting their deaths, has meant that coverage has been complete or near-complete and the data obtained hard enough evidence for reliable lessons to be learned.
The two databases were combined in 2003 as the Confidential Enquiry into Maternal and Child Health (CEMACH), which was to look at morbidity as well as mortality. Dr Gale Pearson, paediatric intensivist in Birmingham and Clinical Director of its child health enquiry, summarizes findings from its report Why Children Die, 2 published in May this year. Two-thirds of the deaths were in hospital and those which were classified as avoidable could be categorized in such a way as to point to where future interventions could be directed. Pearson points to children being assessed by professionals untrained in paediatrics or unsupervised by those who are; difficulties in assessing acute febrile illness and recognizing potentially serious disease; and failure to follow up children after hospital discharge.
Dr Martin Ward Platt, paediatrician in Newcastle and clinical lead for the CEMACH child deaths project in his region, fleshes out the report by using clinical vignettes from it to analyse factors which appear to have led to death. Not all fall into the categories described by Pearson. Some lie outside the role of what might be called the curative services: a child sustains fatal multiple injuries in a road traffic incident because he is not wearing a seatbelt; emotional vulnerability, unrecognized by care staff, leads to an adolescent killing herself; an inadequately supervised offender commits a further crime which kills a child.
A case report by Magi Young, partner in Parlett Kent, solicitors, tells the story of an infant who might well have fallen into the CEMACH category of death due to failure to recognize potentially serious disease. Thankfully, the prompt action of her grandmother – who recalled the ‘tumbler test’ for meningococcal septicaemia – and effective resuscitation at the receiving hospital allowed this child to survive, albeit with injuries leading to disabilities judged as due to clinical negligence. Ms Young concludes with what she considers the case that can teach doctors namely the need to be able to determine, by history and examination, whether a non-verbal infant's consciousness is impaired; and what it can teach lawyers, most of all that the credibility of witnesses may be more cogent than what is written in medical records or inferred from inconsistencies in accounts.
Turning away from children, Hugh Rogers from the NHS Institute for Innovation & Improvement describes its project (building on that of its predecessor body) with a number of hospitals, including some with a high standardized mortality rate (HSMR). Using case-note audit, serious untoward incident reports and senior managers simply talking to staff, likely causes were identified and strategies and tactics devised to find solutions. Rogers emphasizes that it is not just clinicians who need to change the way they behave – managerial leadership being essential to success.