Harriet Smith, Risk and Safety Specialist – Healthcare
Harriet Smith Risk and Safety Specialist – Healthcare

Having worked for many years in the healthcare sector, and being passionate about raising the quality of care and the continual improvement of patient safety, I find these remarks and statistics soul destroying.  If they are even nearly accurate – and we have to believe that they are; then we have to sit up and take some real and decisive actions; we cannot just wait, we need to intervene and act fast.

The research conducted by the London School of Hygiene and Tropical Medicine suggests that the routinely utilised standardised mortality rate should not be used as a benchmark for quality of care, as there is no significant link between them and the number of ‘avoidable’ deaths.  Are hospitals even measuring the right things in order to identify failures and make improvements?

From a risk management and quality assurance perspective the article then goes on to quote Helen Hogan, a former GP and public health expert, who says that ‘only by instigating an independent review into contentious patient deaths could you actually describe a patient’s death as ‘avoidable’.

‘A case review of patient notes is the only way of making a decision about the quality of care. Even then it takes the judgement of Solomon to decide whether a frail, elderly person has died because of a clinical mistake’.

Having spent the last ten years auditing the patient health record across a number of healthcare sectors, I am well placed to agree that numerous learning opportunities would be uncovered if this practice were to take place.  It would be interesting to know how many hospitals, actually conduct internal audit into this area as a matter of course.  Do any hospitals routinely pull the notes of a patient and conduct an internal review – not just for those patients who have been at the centre of a serious untoward incident, or a serious complaint or claim; but for others who have died in less obvious situations?  Not only that, but why leave it so late – why not have a clinical review of records on a routine basis, pick up poor quality care before an unnecessary death – why be so reactive?  Why wait until there is a death?  Should external audit place more reliance on the complete health record of a patient, scrutinising decisions made and actions taken?

I would imagine that a huge amount of learning would be produced as a result; and such a review would, most certainly uncover numerous flaws in healthcare systems.  Yes, it would be a time consuming and uncomfortable exercise, holding a mirror up to expose warts and all – even down to individual practitioner level.  In addition it would produce many questions and many ethical problems – not in the least, what do we mean by ‘avoidable’?

The review of patient health records should be integral to a healthcare organisations quality management system.  Results should be collated and analysed so that any trends and common occurrences can be uncovered; and any unacceptable practice identified and eliminated.  The written health record provides us with an insight into the many millions of patient contacts which are made in hospitals each day, a keyhole to the complex world we work in; therefore not fully utilising them would be a greatly missed opportunity.


  • Randeep Ramesh, ‘750 avoidable deaths a month in NHS hospitals, study finds’, Guardian Tuesday 14th July 2015