Consequences of the emergency response to COVID-19: a whole health care system review in a single city in the United Kingdom.

BACKGROUND: The response to the COVID-19 pandemic in the United Kingdom included large scale changes to healthcare delivery, without fully understanding the potential for unexpected effects caused by these changes. The aim was "to ascertain the characteristics of patients, uncertainty over diagnosis, or features of the emergency response to the pandemic that could be modified to mitigate against future excess deaths". METHODS: Review of the entire pathway of care of patients whose death was registered in Salford during the 8 week period of the first wave (primary care, secondary care, 111 and 999 calls) in order to create a single record of healthcare prior to death. An expert panel judged avoidability of death against the National Mortality Case Record Review Programme scale. The panel identified themes using a structured judgement review format. RESULTS: There were 522 deaths including 197 in hospital, and 190 in care homes. 51% of patients were female, 81% Caucasian, age 79 ± 9 years. Dementia was present in 35%, COVID-19 was cause of death in 44%. Healthcare contact prior to death was most frequently with primary care (81% of patients). Forty-six patients (9%) had healthcare appointments cancelled (median 1 cancellation, range 1-9). Fewer than half of NHS 111 calls were answered during this period. 18% of deaths contained themes consistent with some degree of avoidability. In people aged ≥75 years who lived at home this was 53%, in care home residents 29% and in patients with learning disability 44% (n = 9). Common themes were; delays in patients presenting to care providers (10%), delays in testing (17%), avoidable exposure to COVID-19 (26%), delays in provider response (5%), and sub-optimal care (11%). For avoidability scores of 2 or 3 (indicating more than 50% chance of avoidability), 44% of cases had > 2 themes. CONCLUSIONS: The initial emergency response had unforeseen consequences resulting in late presentation, sub-optimal assessments, and delays in receiving care. Death in more vulnerable groups was more likely to display avoidability themes.

Learning from hospital deaths.

Current guidelines and regulations require trusts to take full responsibility for deaths within their premises. Higher than expected deaths indicate poor standards of care or negligence. NHS Trusts need to put systems in place to ensure that they learn and extrapolate risk factors through in-depth review of care provided to patients prior to their deaths, curb and ultimately diminish relative mortality through improved practices, and improve care and safety for the whole organisation. Mortality reviews can provide insight into the standard of care that dying patients receive; this matters as NHS Hospitals are the main providers of terminal care, nationally.

Stroke mortality audit using the Structured Judgement Review method.

Mortality data provided by the Sentinel Stroke National Audit Programme demonstrated the Royal Cornwall Hospitals Trust (RCHT) to have a higher than national average mortality ratio.1 In response to this, the RCHT stroke department undertook a mortality review of patients admitted with stroke making use of the Structured Judgement Review (SJR) process.2The review found all patients were deemed as receiving adequate, good or excellent care. There were no cases where death was deemed as definitely avoidable. The team found the SJR to be a useful, validated tool for mortality review though recognised specific limitations to its use and wider limitations within our review process. Focused areas for improvement derived from the review included improving compliance with local palliative care guides, improved documentation, links with primary care via Care Quality Commission atrial fibrillation group and consideration of improved scanning facilities. We also acknowledged wider unaccounted factors which may impact stroke mortality and thus influence perceived mortality ratios.

Hindsight bias critically impacts on clinicians' assessment of care quality in retrospective case note review.

Objective To determine whether hindsight bias impacts on retrospective case note review using a five point scoring system based on modern clinical governance toolkits. Design Survey. Setting Clinicians of varying grades invited to complete a short internet survey. Participants Ninety three clinicians were invited to complete an anonymous survey in which they reviewed three case vignettes for the purposes of a fictional clinical governance meeting. For each vignette, participants were randomised to an outcome in which the patient made a full recovery or alternatively died shortly after discharge. Main outcome measure. Participants submit scores from 1 to 5 to indicate the quality of care provided to patients prior to their discharge. These scores were compared to determine whether judgements about the quality of antecedent care were biased by the description of a patient death. Results In two out of three case vignettes clinicians exhibited marked hindsight bias. In a case of a patient with a swollen leg, identical antecedent care was scored as poor by participants when the patient died the next day, but good when the patient recovered (p<0.00001). In a case of headache, care was scored as poor when the patient died but adequate when the patient made a full recovery (p=0.0003). A third case of chest pain did not exhibit hindsight bias. Seniority of clinician had no impact on the tendency to exhibit hindsight bias when reviewing case notes. Conclusion In some cases, clinicians are markedly more critical of identical healthcare when a patient dies compared to when a patient survives. Hindsight bias while reviewing care when a patient survives might prevent identification of learning arising from errors. Additionally, we predict hindsight bias combined with a legal duty of candour will cause families to be informed that patients died because of healthcare error when this is not a fact.