The Clinicians’ View

1. We think about patients, not populations Reviewing from a population view is about what happened Reviewing from a patient view is about what should have happened Hindsight bias Poor care bias – even if it made no difference The Clinicians’ View

2. Most cases are fairly easy to scoreand in South Tees most are a Hogan grade 1 or 2

3. Three quick cases based on real cases in South Tees

4. An Easy 1

5. Aet 97 • Care Home Resident • Mild CFF due to IHD • PPM

6. Right sided weakness • Partial Anterior Circulation Stroke • Probably during night - found 0730 • CT at 0900 • Thrombolysis at 0944 - alteplase - direct consultant supervision • On stroke ward by about 1030 • Next day alert, sitting out, but aphasic

7. Good all round care • Some notes unclear or difficult to read • SALT done early • Good rehab • MDT plans by day 14 for placement

8. Around day 16 seems to have developed aspiration pneumonia • Appropriate re-review of swallow • Appropriate antibiotics and physio • ABG & DNAR • Drowsy • "Unlikely to survive" • But re-site cannula and vancomycin

9. Next day antibiotics changed on med micro's suggestion • And truly a good bit of intrusive care • Two more days before "ensure comfortable" • But still physio • Next day EOLCP • But only for hours

10. I am not wholly proud of this care, but it is a 1 • We plugged on too long with unpleasant treatment, neglect of palliation when we knew how guarded her outlook was • But it is still a 1

11. A straight 6

12. Aet 71 • Known AAA under surveillance • IHD • PVD

13. GP referral • Known AAA - 5.1 cm • Midline pain spreading through to back • A&E ? Leaking AAA

14. A&E noted AAA • CT aorta within 30 minutes of arrival. Not leaking but now 5.9cm • ? Renal colic, ? Diverticulitis • Admit surgeons • Discuss with vascular • Imaging shows no stone and no clear diverticulitis

15. Day 3 "pain over AAA ++" • Refer vascular • Seen later on, less tender, but pain is postural and radiates to back • MDT Friday

16. Several comprehensive reviews • All by FY1 in the night • No clear diagnosis made • All presumptive diagnoses trivial with no supporting evidence

17. Continued to have low grade reviews, pain but no progress • Day 7 0145 - it burst • In point of fact we didn't do that well with trying to fix it then, but as the presentation was PEA, Hb 5 the disorganised response was probably unimportant.

18. There were odd features in the presentation • But he wasn’t re-imaged and he doesn’t seem to have any high level reviews that actively questioned the putative trivial diagnoses • Our urgent AAA results mean his risk of death with surgery was very low

19. A 6 or a 1?

20. A big chap • Aet 76 • # NOF • AF – poorly controlled

21. Rate control with metoprolol • Operation went well • Back to ward looking OK

22. AF speeds up and BP falls • Nothing else obviously wrong • Med Reg gives advice on the ‘phone • More metoprolol • Immediate terminal decline • Bloods come back too late - Hb 6

23. The bleeding was not obvious • AF speeding up is common in these circumstances • Catastrophic bleeding is rare • So in the original team’s shoes…