Interview conducted by April Cashin-Garbutt, BA Hons (Cantab) on 17th July 2012
Your recent research suggests that 12,000 deaths a year could be prevented in English hospitals. Please could you tell us how your research into this topic originated?
In 2007/8 when we were thinking about the study, there wasn’t a clear picture of the number of preventable deaths in English hospitals. There had been an important report by the chief medical officer of the NHS in 2000 (An Organisation with a Memory) and he talked of the possibility of between 60,000 and 250,000 cases of severe disability or death arising in hospitals.
Other reports mentioned estimates of 40,000 deaths. These estimates were mainly based on studies from other countries, particularly the USA where researchers had identified the number of adverse events occurring in patients who went on to die but had not analysed whether the event actually caused the death. We also didn’t know which particular groups of patients were most at risk.
Please could you explain to us what causes of death your research showed to be preventable?
The three most common causes of problems in care linked to preventable deaths were related to clinical monitoring (31.3%); diagnosis (29.7%) and problems with drugs and fluids (21.1%). The large proportion of problems occurred whilst the patient was receiving care on the ward (40%). Others occurred early in admission; during an operation or post-operative care.
Is the number of preventable deaths higher for any particular condition or type of person? For example, is the rate of preventable deaths any higher for older or younger patients?
Our study showed that older patients are more vulnerable to serious harm leading to death as a result of problems in their care. The average age of a patient who had a preventable death was 78 years old. The majority of these patients also had four or more separate conditions when they were admitted to hospital and 60% were judged to have less than a year of life left to live.
Our findings are similar to other studies that show higher rates of adverse events in older patients with multiple conditions and also that they are more vulnerable to serious harm from these events. Older patients are more likely to need closer attention paid to monitoring their response to treatment and to ensure that the treatment doesn’t lead to harmful side effects. If these things don’t happen then harm is more likely to occur due to the patient’s frailty.
Why do you think English hospitals are failing to prevent these deaths?
It is important to remember that in our study the case reviewers thought that the vast majority of patients had good quality of care. Only in 3% of the 1000 cases studied was the quality of care judged as poor.
Acute hospital care is increasingly complex. Not only are the patients being admitted as emergencies older and sicker but the range of treatments that can be given has grown, some of which have the potential to have serious side effects as well as benefits.
Providing modern care takes a high degree of coordination and cooperation within teams of doctors and nurses and across different specialists. Within such a system the possibilities for errors is always present. We found that most errors were related to omissions such as failures to diagnose an underlying condition or failures to monitor the patient or respond quickly enough if the monitoring indicated a deterioration.
How do preventable death rates in NHS hospitals compare to private hospitals in the UK?
We don’t know how it would compare to private hospitals as our work was carried out in NHS hospitals.
Private hospitals, however, tend to deal with younger patients than the NHS and less acute emergencies; therefore the patients are probably not as sick and vulnerable to things going wrong.
How do the number of preventable deaths in English hospitals, as a whole, compare to other hospitals in the world?
Internationally, not many studies have been done that look at this issue. There was a small study done in America and that came up with a figure of 6% for preventable deaths.
A larger study in the Netherlands, which studied nearly 4,000 patients who died, came up with a figure of 4.1%.
These studies came before ours and gave us a guide as to what we might find. Our finding of 5.2% of deaths being preventable is similar.
How could English hospitals decrease the number of preventable deaths each year?
I think it is important for hospitals to measure the rate of severe harm and death caused by problems in care and track these numbers over time. It is also important to look in more detail at cases where things have gone wrong and understand how to prevent such harm in the future.
The typical patient coming in to hospital now is different to what it was 20 years ago. People are living longer, they have more illnesses as they get older and present to emergency care very sick. Hospitals need to be organised so that they can provide high quality care, consistently for this type of patient.
This does not really involve anything new; it is just that the procedures need to be done reliably such as:
- Broader assessment of patients as they come into hospital rather than just looking at their acute conditions. Their different diseases need to be looked at along with other factors that might affect healing in order to assess the risks as well as the benefits of any proposed treatments
- Having clear management plans, supervised by senior doctors with regular follow up of patients progress
I think good team working, senior supervision of junior doctors and good nursing leadership on the wards are needed to guard against omissions in care.
Are there plans in place to achieve this?
A lot of change is happening in the NHS since our study in 2009 which should benefit patient safety. Most hospitals now have acute admission units, with consultant cover, where patients can be assessed and stabilised before being sent to the wards. There is also a lot more involvement of care of the elderly doctors with patients admitted under other specialties such as surgery or orthopaedics. Their expertise can make sure that a patients medical problems are treated optimally. There has also been a lot of work to develop nursing leaders on the wards.
There are also tools that can be used to deliver more reliable care. For example, specially designed forms let nurses know when a patient’s observations are deteriorating and when to call the doctor to undertake an urgent review.
Some hospitals also have quite sophisticated computer technology that flag up potential drug side effects, allows them to track whether medicines have been given on time or whether risk assessments for falls or thrombosis have been carried out, almost in real time. The right technology can help us to avoid problems in care.
How do you see the future of preventable hospital death rates progressing in England and the rest of the world?
I think it is good that we now have a baseline figure for preventable deaths, as it is important to determine whether we are improving. Measuring and learning from serious harm will highlight where efforts still need to be made to improve safety. There are a lot of changes that are happening that I would expect to have a positive impact on preventable deaths in the future.
Do you plan to do any further research into this field?
We don’t know much about the levels of severe harm and preventable death occurring outside of hospitals, such as in primary care or across the interface between primary and secondary care. It is a potential area for future research, but may be challenging when it comes to collecting the information required.
Where can readers find more information on this topic?
The National Confidential Enquiry into Peri-operative Deaths have a number of reports highlighting risks of hospital care: http://www.ncepod.org.uk/
The Royal College of Physicians have a future hospitals project, which is considering how hospitals should be designed in the future to avoid these sorts of problems: http://www.rcplondon.ac.uk/projects/future-hospital-commission
The Health Foundation, which is doing a lot of work on hospital safety: http://www.health.org.uk/
About Dr Helen Hogan
I originally trained in family medicine and combined working in a group practice with a teaching fellow post in the Department of Primary Health Care and General Practice, Imperial College School of Medicine. As part of the Clinical Governance team in my Primary Care locality I took part in quality assurance visits to other family practices.
This stimulated my interest in quality improvement in health services and prompted a shift of careers into public health. In 2006 after completion of a 5 year training programme, I took up a post as Clinical Lecturer in Public Health in the Department of Health Services Research and Policy at the London School of Hygiene and Tropical Medicine.
Since this time my research has focussed on measures of safety in acute hospital settings in collaboration with researchers at the National Patient Safety Agency, the National Institute for Health Research Centre for Patient Safety & Service Quality, Imperial College London and the Institute of Health and Society, Newcastle University. I am also a Course Director for the MSc in Public Health, the largest such programme in the UK.