Professor Sir Bruce Keogh
National Medical Director
NHS England
Richmond House
79 Whitehall
London SW1A 2NS
26 April 2017
Dear Sir Bruce
Supporting the NHS to reduce avoidable death
We would like to find additional ways to contribute to the aspiration to make the NHS the safest
and most transparent healthcare system in the world. You may recall we provided support and
analysis for the National Review of High Mortality Hospitals you led in 2013 and since then we
have been working with Sir Mike Richards for the CQC’s horizon-scanning and targeted hospital
reviews as well as many of the better quality NHS providers. From this we have developed a
respected following and engagement with many Medical Directors and clinical leaders locally.
Our recent March conference (‘Exploring how we can materially and sustainably shift the dial on
avoidable harm’), where both Sir Mike Richards and Ascension Health (US) presented, was
attended by many Medical Directors and Governance Leads. A particular focus of the
discussion was on how best to achieve our shared goals on avoidable death. Two messages
became clear:
1. We can create time and opportunity for medical staff with a structured automated triage tool,
to focus on learning from what has gone wrong and can be remedied, rather than simply
collecting the data and ticking the box. An outline for the methodology to achieve this is
annexed to this letter.
2. There is a real clinical consensus that we should not stop there: that zero-avoidable harm
should be the aspirational goal of every Trust Board in the NHS and that the System could
learn a lot from Ascension’s journey and approach. This would dovetail neatly with the new
direction of travel for NHS Resolution.
Over the last decade C-Ci (CRAB Clinical Informatics), has been supporting a variety of
healthcare providers not just in the UK, but across Europe, Canada, the USA and Australia/New
Zealand with tools that effectively engage the clinical body to improve safety and quality, while
reducing unwarranted clinical variation and delivering significant cost-savings. There are proven
examples from this work that can genuinely help the NHS move further and faster in delivering
your policy goal.
CRAB Clinical Informatics Limited
Address for correspondence: C-Ci 2a / 2b Oakington Business Park Cambridge CB24 3DQ, England
Registered office: 3, Ye Corner, Aldenham Road, Watford, Herts WD19 4BS UK
Registered Company number: 6601066 VAT Registration number GB 936 4035 26
w: www.c-ci.co.uk t: 020 8144 6967 e: [email protected] w: www.help.c-ci.co.uk
I should welcome the opportunity to discuss this with you in more detail and take your steer on
the most appropriate way for us to support the process.
I have taken the liberty of copying this letter to Sir Mike and the respective Presidents of the
Royal College of Physicians and the Royal College of Surgeons, as I believe we all share the
same aspirations and I should likewise be happy to progress this discussion with them.
Yours sincerely,
Mr. Graham Copeland MB BS FRCS ChM
Consultant General Surgeon
Chief Medical Officer, C-Ci
Formerly National Director of Clinical Audit, Department of Health
Copy:
Prof. Sir Mike Richards, CQC
Prof. Jane Dacre, Royal College of Physicians
Clare Marx, The Royal College of Surgeons
CRAB Clinical Informatics Limited
Address for correspondence: C-Ci 2a / 2b Oakington Business Park Cambridge CB24 3DQ, England
Registered office: 3, Ye Corner, Aldenham Road, Watford, Herts WD19 4BS UK
Registered Company number: 6601066 VAT Registration number GB 936 4035 26
w: www.c-ci.co.uk t: 020 8144 6967 e: [email protected] w: www.help.c-ci.co.uk
ANNEX
Delivering a consistent and scalable approach to reduce avoidable mortality
Current situation
1. The average general NHS hospital trust will see over 120 deaths per month. So it is important that
there is a consistent way to triage cases quickly to identify and learn from the minority of cases where
death or serious harm was truly avoidable by undertaking a detailed case record review, using the
Royal College of Physicians’ process (RCP).
2. Detailed case record review of all deaths has been acknowledged as both impractical and unlikely to
reveal any additional benefit given the great majority of deaths relate to natural causes. It also risks
creating a “box-ticking” exercise where more effort is directed at gathering the data than in learning
from errors.
3. By contrast, random sampling of a smaller number of cases for review has the danger of adding
subjectivity, missing significant errors or omissions and therefore camouflaging potential problems.
4. To be effective, and to reassure the public that transparency and accountability is being applied
uniformly across the NHS, triage needs to apply to all deaths without random sampling (albeit certain
categories specified in the RCP’s guidance should automatically be included such as Patients with
Learning Disability, Coroner’s cases, active complaints etc.).
Recommendation
5. Automating the first stage of triage for all deaths, will allow RCP review of mortality cases where it
really matters and free up clinical resource to then learn from the issues and make the appropriate
organisational changes. This way we can achieve real alignment between management reporting and
what clinicians are passionate about i.e. delivering good care and improving quality.
6. A variant of the Global Trigger Tool (GTT) can be used for this. The GTT contains “triggers” or clinical
clues that help to identify potential errors, omissions, or adverse events in the course of a patient’s
care. The GTT was originally based on manual sampling, but automated capture of GTT-style triggers
is now possible for all patients admitted to hospital, enabling continuous review of all patient care in
all specialties over time.
7. It is clear from running the automated process around the world that the more triggers a patient
experiences, the more a “snowball effect” takes hold, with the patient rapidly deteriorating and
ultimately becoming susceptible to serious harm and eventually death.
8. It is also clear from the international data that the risk of death suddenly increases nearly three-fold in
patients experiencing 4 or more triggers when compared with patients with 3 trigger events. It is in
this cohort of patients where deaths may have resulted from mistakes or omissions are invariably to
be found. This cohort of patients is also small (typically <20% of the total number of fatalities).
9. Accordingly, an automated triage solution to aid detection of the small number of deaths that may be
avoidable, based on identification of patients with multiple triggers of avoidable harm together the
RCP’s mandatory categories, would ensure that scarce clinical time is focused on the cases where
real problems are evident, where change is needed and avoid the hazards of bias and omission.
CRAB Clinical Informatics Limited
Address for correspondence: C-Ci 2a / 2b Oakington Business Park Cambridge CB24 3DQ, England
Registered office: 3, Ye Corner, Aldenham Road, Watford, Herts WD19 4BS UK
Registered Company number: 6601066 VAT Registration number GB 936 4035 26
w: www.c-ci.co.uk t: 020 8144 6967 e: [email protected] w: www.help.c-ci.co.uk