The Clinicians’ ViewWe think about patients, not populations

Reviewing from a population view is about what happened

Reviewing from a patient view is about what should have happened

Hindsight bias

Poor care bias – even if it made no difference

Most cases are fairly easy to score

and in South Tees most are a

Hogan grade 1 or 2

Three quick cases based on real cases in South Tees

An Easy 1

• Aet 97

• Care Home Resident

• Mild CFF due to IHD

• PPM

• Right sided weakness

• Partial Anterior Circulation Stroke

• Probably during night - found 0730

• CT at 0900

• Thrombolysis at 0944 - alteplase - direct consultant supervision

• On stroke ward by about 1030

• Next day alert, sitting out, but aphasic

• Good all round care

• Some notes unclear or difficult to read

• SALT done early

• Good rehab

• MDT plans by day 14 for placement

• Around day 16 seems to have developed aspiration pneumonia

• Appropriate re-review of swallow

• Appropriate antibiotics and physio

• ABG & DNAR

• Drowsy

• "Unlikely to survive"

• But re-site cannula and vancomycin

• Next day antibiotics changed on med micro's suggestion

• And truly a good bit of intrusive care

• Two more days before "ensure comfortable"

• But still physio

• Next day EOLCP

• But only for hours

I am not wholly proud of this care, but it is a 1

We plugged on too long with unpleasant treatment, neglect of palliation when we knew how guarded her outlook was

But it is still a 1

A straight 6

• Aet 71

• Known AAA under surveillance

• IHD

• PVD

• GP referral

• Known AAA - 5.1 cm

• Midline pain spreading through to back

• A&E ? Leaking AAA

• A&E noted AAA

• CT aorta within 30 minutes of arrival. Not leaking but now 5.9cm

• ? Renal colic, ? Diverticulitis

• Admit surgeons

• Discuss with vascular

• Imaging shows no stone and no clear diverticulitis

• Day 3 "pain over AAA ++"

• Refer vascular

• Seen later on, less tender, but pain is postural and radiates to back

• MDT Friday

• Several comprehensive reviews

• All by FY1 in the night

• No clear diagnosis made

• All presumptive diagnoses trivial with no supporting evidence

• Continued to have low grade reviews, pain but no progress

• Day 7 0145 - it burst

• In point of fact we didn't do that well with trying to fix it then, but as the presentation was PEA, Hb 5 the disorganised response was probably unimportant.

There were odd features in the presentation

But he wasn’t re-imaged and he doesn’t seem to have any high level reviews that actively questioned the putative trivial diagnoses

Our urgent AAA results mean his risk of death with surgery was very low

A 6 or a 1?

• A big chap

• Aet 76

• # NOF

• AF – poorly controlled

• Rate control with metoprolol

• Operation went well

• Back to ward looking OK

• AF speeds up and BP falls

• Nothing else obviously wrong

• Med Reg gives advice on the ‘phone

• More metoprolol

• Immediate terminal decline

• Bloods come back too late - Hb 6

The bleeding was not obvious

AF speeding up is common in these circumstances

Catastrophic bleeding is rare

So in the original team’s shoes…