I know
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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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Then you imagine wrong. Many ICU patients die on a pathway. There are plenty of the remaining group, not admitted to due, but path appr.
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Really? So there's a notable volume of pts who don't arrive in hospital in a condition which would indicate that their death is imminent, but who then subsequently find themselves on the death pathway anyway? You're right, I did imagine wrong. I'm quite surprised by that.
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Yes, though if we sat and discussed case, you would say events were predictable. Dementia and frailty dominates. Final wks unpredictable
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Fair enough. I can see that. So out of interest, how do you ensure pt's deterioration onto a death pathway has not resulted from some unseen, underlying problem with the care they received?
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The crucial step that allows candour is immediacy. We do the reviews the week the patient dies. No reopening of wounds.
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And I absolutely applaud you for this. Speed is of the essence. A family's desire for answers can leave their imagination to eat away at them over time. How soon do you share findings with the families?
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...and thank you Martin, for taking the time to respond. Much appreciated.
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The first part of the conversation can happen in days. Later parts vary. The first contact is the essential one.
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Reviewing deaths where the family is unhappy is just sensible! It helps everyone.
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Totally agree with your thinking here.
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I am sure Martin will comment. he has huge experience and expertise
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Thanks Umesh. I was delighted to find that Martin already follows me. I feel honoured...
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