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Did he have to die?

My dad died in hospital in June. I suspect that his death wasn’t inevitable.

He was 91, he had sepsis, which is difficult to spot, and it happened in the middle of the night.  So it would be hard to blame the hospital for his death.  (A US study that reported in February suggested that only 12% of hospital sepsis deaths might have been preventable.)

Coincidentally, a few weeks before, I had applied to sit as a patient representative on the Mortality Surveillance Group, that investigates deaths in hospital, in our local acute trust (a different one from where my dad died).

So, having already learned a little about mortality reviews and also (through an unrelated one-day workshop) about sepsis, I did wonder how inevitable his death really was.  It is possible to spot the signs, and with more and maybe better trained staff, and improved monitoring, perhaps it could have been identified and immediate action taken to deal with it.  That might not have been realistic given where this particular hospital was (‘requires improvement’) and the pressures the NHS is facing more generally, but perhaps in theory there might have been a chance of saving him.

I thought about asking the hospital to do a mortality review.  I was going to propose that they didn’t report back to the family, with a view to it being a genuine learning, rather than defensive, exercise.  However, I wasn’t sure they would actually do that (they would want to follow their procedures and protocol).  It would also have involved a lot of discussion with siblings to make sure they were happy with it at what was already a difficult time.  And in any case I had more than enough other things to do.  So in the event, I didn’t take it any further.

So are there any lessons I can learn from this for my forthcoming role as patient representative on the mortality surveillance group?  Perhaps that you can’t rely on pressure from relatives to alert you to where investigation might be worthwhile – if I didn’t end up doing it when I have some idea how the system works, how likely is it for others?  On the other hand, if I had raised it, perhaps that would have meant resources going on an investigation that was less worthwhile than other possible ones.  And in any case, would there have been a worthwhile investigation leading to change or just time spent justifying what happened (which might actually be a reasonable conclusion) but without thinking if they could do better.  So I suppose the key thing is that improvement really depends on the institution itself wanting to change.

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