Without an accountable "system" where roles & responsibilities are defined as part of a quality system I'm not sure we can break free of the cycle. When I see a "whistle blower" I see someone who actually did their job. Perhaps social action from patients/public would help.
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When I do Structured Death Review the starter questions are Date Day Time admitted? This can take 15minutes trawling various notes and systems to discover we don’t know for sure. That’s how unusable our information and systems are ..
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For The current death review I am doing I could find the time patient clerked but not the arrival time in Hospital after transfer from another NHS Hospital with no transfer letter. I then had to look up in a calendar which day of the week that was ...
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Presumably I am meant to be looking for possible failures leading to a possibly Avoidable Death but actually spend huge amounts of time working out dates & times. Generally no information about seniority of Doctor Doing the Daily Review. Usually no Problems List
#LarryWeed -
So the NHS does not prospectively collect information in usable formats to establish timelines - timeline is vital for Diagnosis & refining Clinical Management, so no surprises to me when it goes wrong. The time taken to Review Notes proves the notes are not fit for purpose
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