Please do - plus evidence of harm reduction “90%” which has been lacking
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In theory death review is good only if it is done properly and with
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Absolutely. I appreciate that. My question is more to do which cases you include for review - and specifically why you choose to exclude those placed on the death pathway.
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1 Unexpected death 2 Family unhappy or has concerns 3 Death which should be referred to
#Coroner and any one has any concerns This is my personal view@martinfarrier is an expert -
Ok, thanks Umesh. Wonder if
@martinfarrier will have any thoughts on this question? The point was discussed at CQC's board meeting just 10m15s into the video >https://m.youtube.com/watch?v=fxh95M_85PM … -
Unexpected death should = a death where anticipatory care is not given. That’s really the deaths we review.
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Appreciated. My concern was the inclusion of those put on the death pathway as a separate category. If they were not admitted to die & not admitted to ICU, I just thought any such pt then put on the death pathway would be reason to investigate death, not exclude. Is it just me..?
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We did multiple months of “death pathway” reviews and found fewer errors. These deaths turned out to be the low risk deaths.
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Interesting, thanks. What kind of volume of pts did this specific category involve? I can't imagine there should be too many who having not been admitted to die, or admitted to ICU, then subsequently find themselves on the death pathway?
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Thank you Umesh...
Thanks. Twitter will use this to make your timeline better. UndoUndo
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We exclude patients on “anticipatory care” or on ICU. that’s about half the patients. We review the other half - the high risk half
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With respect, but depends on definition of risk. Reviewing care of dying patients also offers much system learning. Harm here is no less important and lessons can apply to all care
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If really 90% expected to die (?) then that's probably where focus of learning should be
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I am a simple man and this is too complicated. What can we learn from someone expected to die? Please educate me
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Surely people expected to die and who trust us to manage a good quality death for them are as important as those who live. Reviewing that process brings either assurance or learning for improvement. You say 90% of your business is in managing death
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I read that as being 90% of the 20-30 deaths per week were 'expected'. That would be some way removed from '90% of Unesh's business being 'managing death' though, no?
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Apologies if I mis-read. In which case its similar to many organisations if we go by HSMR. We converted from 100% mortality review to about 20% random selection with no change/loss in learning themes. More manageable?
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