An inquest into the death of a patient in a Milton Keynes hospital was completed on May 17, 2013 by the local coroner. The coroner found that the staff failed to take and report appropriate observations and render effective treatment. Diagramming the cause-and-effect relationships identified in the inquest in a visual root cause analysis, or Cause Map, allows identification of lessons learned and possible solutions to reduce the risk of this type of incident happening again.
We begin with the impacts to the goals. In this case, the patient safety goal is impacted due to the patient death. It was suggested that nursing shortages may have been related to the issues that occurred. If this is the case, the shortages would impact employees. The inquest that resulted due to the patient death can be considered an impact to the compliance and organization goals. Last but not least, the insufficient patient treatment is an impact to the patient services goal.
Beginning with these impacted goals, we can ask Why questions to determine the cause-and-effect relationships that resulted in the patient death. In this case, the patient death was due to respiratory arrest caused by an obstructed airway. The patient being placed on her back while unconscious (though sources differ on whether the patient was placed on her back or her side) due to a drug overdose. The patient overdose was due to a self-administered overdose and not being administered the antidote for the drugs on which she had overdosed.
The patient was not given an antidote for the drugs on which she overdosed. The family of the patient, who had a history of mental illness and frequented the hospital, believes that the staff believed she was faking her symptoms.
Through the patient’s eleven hours within the hospital’s Accident & Emergency (A&E) Department, only 2 formal observations were recorded. One set of observations was recorded on a glove, which was later lost. Abnormal results from these observations were not passed along from the healthcare aid who was responsible for the patient, likely due to nursing shortages.
Once all of the causes related to the incident have been recorded within the Cause Map, solutions can be brainstormed and recommended for implementation. The coroner involved in the case has requested the Secretary of State for Health implement changes that would require seriously ill patients to be observed by nurses rather than healthcare assistants. The hospital has stated that they “have conducted an investigation to ensure lessons are learned” and “will be continuing to improve our service in regard to emergency patients”. The hospital has commissioned training for their healthcare assistances to improve their skills.
To view the Outline and Cause Map, please click “Download PDF” above.