Putting a stop to preventable deaths

Since the publication of the final report by Robert Francis QC on the Mid Staffordshire scandal, many column inches have been devoted to the different ways hospital mortality is reported. It is important to remember however that these outcomes constitute a composite of the deaths of hundreds of individual patients and as the Cure the NHS campaigners in Stafford would tell you, each one really matters.

It stands to reason therefore that attempts to improve composite outcomes must start with meaningful inquiry of each death and action to deal with identified preventable causes.

‘Florence Nightingale was the first on this side of the Atlantic to appreciate the importance of outcomes measurement’

There are different ways the death of any individual patient can be examined. In certain situations, such as a diagnosis of one of a number of certain infectious diseases or a death occurring within a certain timeframe after surgery, the death is reported to the coroner. An inquest is held, the purpose of which is to establish the facts as they occurred and a cause of death.

If a preventable cause is identified, the coroner can − and often does − ask the relevant organisation to ensure changes to prevent a recurrence are put in place. Most deaths in hospital, however, are not coroners’ cases.

As part of its response to the Dame Janet Smith inquiry into the murder of patients by Harold Shipman, the Department of Health has been working with a wide range of organisations to simplify and strengthen the process of death certification. The proposed changes will require the certified cause of all deaths that are not investigated by a coroner to be independently scrutinised and confirmed by a locally appointed medical examiner.

Examining death

Over the past few years, medical examiners have been put in place in a number of pilot sites. In Sheffield, one of the pilot sites, two medical examiners have been appointed.

When a death occurs, a junior doctor or consultant rings the duty medical examiner and briefly discusses the case on the phone. The medical examiner decides whether the case needs to be referred to the coroner or whether the team in charge of the patient who has died can issue a death certificate.

If the latter applies, the medical examiner needs to know − or often suggests − what the certifiable cause of death should be. They do not have the time or opportunity to scrutinise the medical notes and identify any preventable factors associated with the death.

The most common way that each hospital death is scrutinised has been through the morbidity and mortality meeting, which allows healthcare staff (traditionally doctors) to meet at regular, usually monthly, intervals to discuss each patient death that has occurred on their watch.

The meeting’s function

This meeting has had a long, chequered history and, although Florence Nightingale was the first on this side of the Atlantic in the 19th century to appreciate the importance of outcomes measurement, the provenance of the morbidity and mortality meeting lies in the US.

‘Despite the obvious changes that are occurring in morbidity and mortality meetings, they are still not taken seriously’

At the beginning of the 20th century, Ernest Amory Codman, a surgeon at Massachusetts General Hospital, developed an “end results” system in which the history and outcomes of certain patients were documented, adverse events were reviewed and causative errors were categorised.

In 1983, the Accreditation Council for Graduate Medical Education in the US made it a requirement for departments with surgical training programmes to hold a weekly review of all current complications and deaths, including radiologic and pathologic correlation of surgical specimens and autopsies.

Rules, conduct and definitions have been passed on over the years but the function of morbidity and mortality meetings, as laid out at their inception in America, has always been both educational and one of quality assurance.

Time to get serious

I have worked in the NHS for 30 years in different medical and surgical firms and during this time I have seen the British morbidity and mortality meeting evolve. The meeting used to be predominantly concerned with mortality in the surgical specialties. Junior doctors presented the deaths of the patients of their bosses (when true firms existed) and acted as lighting rods for the barbed comments that consultant surgeons hurled freely at each other.

Over the years they have evolved (and consultant surgeons have grown up); meetings are now held in many medical, as well as surgical, specialties and, in addition to death discussions, include the reporting of morbidity outcomes and critical incidents. As the perception grows that quality improvement is a significant raison d’être for morbidity and mortality meetings, requests for written evidence of these meetings have been received in Sheffield from the coroner and the NHS Litigation Authority.

What is significant and welcome is a recent increase in the number of requests for reports from the families of patients who have died. Despite the obvious changes that are occurring in morbidity and mortality meetings, they are still not taken seriously.

Culture deficit

Three years ago I undertook a UK-wide audit of meetings in a number of surgical specialties. I was disappointed − if not surprised − to find that a significant percentage of surgeons did not attend any morbidity and mortality meeting, felt they were of no value or never discussed near miss events.

‘These meetings need to be a central part of the culture change that is urgently needed in NHS hospitals’

Non-medical staff were invited to less than 50 per cent of the meetings and less than half of presentations were given in an agreed format. When systemic errors were identified, an astonishing 17 per cent of surgeons admitted that no follow-up action was taken.

These figures reflect the serious culture deficit relating to quality improvement and patient safety that still exists in many NHS hospitals. It is this that Robert Francis is trying to address in his report.

It is perhaps unsurprising that of the hundreds of excellent and useful publications that exist on the role of morbidity and mortality meetings in quality improvement, only a handful originate in the UK. It is ironic that although Robert Francis states the importance of critical incident reporting, he does not even mention morbidity and mortality meetings in his report.

These meetings need to be a central part of the culture change that is urgently needed in NHS hospitals. In my mind, the “modern” morbidity and mortality meeting needs some key ingredients:

• Meetings must be planned in advance and clinically led − though not necessarily by a doctor.
• There must be standardisation of how the meetings are conducted across trusts or maybe even across the service as a whole. In the Sheffield cardiothoracic morbidity and mortality meeting, we use a set of questions designed by the National Confidential Enquiry in Patient Outcome and Death to assess the quality of administered care combined with further questions designed locally.
• The meetings need to have adequate secretarial and logistic support, and must be held frequently − possibly even weekly − if details of deaths are to remain fresh in people’s minds.
• Time devoted to these meetings and for their planning must be sacrosanct.
• The invited audience must be multidisciplinary and crucially must include service managers and a patient governor. Attendance at meetings should be part of the appraisal of everyone involved in healthcare. 
• There must be liberal use of root cause analyses. If a death is deemed avoidable, a time limited plan of action is required, together with a demonstration of its completion at a future meeting.
• Individual reports as well as minutes of the meeting must be fully recorded.

What patients deserve

Most deaths are inevitable but a significant proportion is avoidable and it is for the future avoidance of these that morbidity and mortality meetings exist. Discussion of deaths is important but for every single avoidable death, there are a number of avoidable near misses. It is even more important for these to be examined and discussed.

There has been standardisation of the reporting of these in recent years. What needs to change is the intended audience of the reports to include those on the front line looking after patients, not just commissioners and regulators.

Time to understand the incidents and how to avoid them in the future must also be an integral part of the new meeting. Every affected patient and their relatives deserve a full investigation and explanation as to why death or a serious complication has occurred.

The tools required to bring about change in the organisation of meetings are already in place; what is needed is a change of culture. This means an appreciation of the supreme importance of any quality initiative such as morbidity and mortality meetings by leaders at all levels, as well as the empowerment of patients and their families to encourage or, if necessary, enforce change.

Norman Briffa is consultant cardiac surgeon at Sheffield Teaching Hospitals Foundation Trust