Case Note Review The "Rolls Royce" Form of Patient Safety Analysis?

Case Note Review The "Rolls Royce" Form of Patient Safety Analysis?

The flaws of using various statistical techniques to estimate the numbers of avoidable deaths in hospitals have been documented in this blog and elsewhere ad nauseum. Thus it should be no surprise that the DoH will be assessing avoidable deaths by the far more reliable methodology of the case note review (disparaged by Julie Bailey for her own reasons). The only superior method would be widespread post-mortems accompanied by coroner's inquests, with all the resource implications. 

This would be an exciting advance in the monitoring of hospital mortality, although it would fail to pick up the major issue of quality of care (which as previously discussed is not reflected well by mortality). It also fails to address the massive falls in post-mortem rates, despite the recognition that post-mortems (whether virtual or orthodox) continue to pick up a high rate of diagnostic error. 

Nonetheless, this move demonstrates a welcome move away from the Dr Foster model of statistical analysis. The avoidable mortality in British NHS hospitals is on a par with that of healthcare systems across the developed world, despite the apocalyptic headlines from tabloid newspapers.