A review of deaths in surgery using the structured judgement case note review process

Abstract

Introduction In December 2016, the Care Quality Commission published a review of how National Health Service trusts investigate patient deaths. Provider organisations and commissioners must work together to review and improve their local approach following the death of people receiving care from their services. Methods The Royal College of Physicians led the National Mortality Case Record Review programme based on the qualitative approach developed by Professor Hutchinson and colleagues at the Yorkshire and Humber Academic Health Science Network. The structured case note review (SCNR) is divided into six phases followed by an overall judgement of the quality of care and of the medical records. We have modified the SCNR to include a section for returns to theatre. The process also includes an assessment of whether any shortcomings in the quality of care contributed to death. Results This paper reports the results of the first 172 SCNRs undertaken in surgery at the Royal United Hospital in Bath. The vast majority (97%) of patients were admitted as emergencies. Overall care was graded as poor in four cases, with problems identified in three cases that were likely to have contributed to death. Two of the recurring themes for learning were failure to escalate a deterioration in the National Early Warning Score and delays in recognising deterioration due to acute surgical problems on medical wards. Conclusions Learning from mistakes is fundamental. The SCNR offers a process to identify both good and poor practice as well as bringing to light previously unrecognised care delivery problems.