Sunday, 17 March 2013

When it comes to preventable deaths– what do we really know?

In early 2009, in the days before the release of the Health care commission report on Mid Staffs there was a gathering of some of the most powerful people in the health service in Richmond House. At that meeting a last minute appendix to the HCC report was produced.  We do not know the detail of this, because it was never published.  It was the consensus of the meeting that it could not be published because there was serious concerns about the reliability of the material, and because it was accepted by all that the contents would cause widespread public concern.

The material was not published and therefore could not be openly questioned, but the leaks based on this document are the source of the 400-1200 excess deaths which have formed the central argument in virtually all press reporting of Mid Staffs over the last 4 years.

It is only now, after the publication of the Francis report which does detail some of the major questions that need to be asked about these figures, that detailed discussion of the excess deaths and the Hospital Standardised Mortality Rate is beginning to be heard quite widely.

 Let us look at some of the documents that are circulating.

Which indicates that we may have been overestimating the number of preventable deaths. It also maps preventable deaths against life expectancy. The study also makes the point that harm is done to the public by raising anxiety about “preventable deaths”.  The study questions if mortality rates are actually the most effective means of measuring quality of care.


There are also implications for policy. While the spectre of preventable hospital deaths may prove helpful in raising interest in patient safety and a commitment to improvement, overestimating the size of the problem and the risk to patients may induce unjustified levels of anxiety and fear among the public. In addition, confirmation of the relatively small proportion of deaths that appear to be preventable provides further evidence that overall hospital mortality rates are a poor indicator of quality of care.

This article for Computer weekly takes a look at the statistical information considered by the Mid Staffs Public Inquiry and comes to the conclusion that it was selective, and has therefore given a misleading impression.  The evidence considered by the inquiry fails to show the major improvements made in mortality rates at the hospital from 2007 onwards and therefore fails to give credit to the work done at the hospital to tackle its problems.

Steve Walker has developed a strong interest in the issues surrounding the Mid Staffs mortality rates and has written this challenging article, which raises major questions about the reliability of story believed by so many people about Mid Staffs.

This was distressing to one of the journalists who had been deeply involved in telling the story and this is a debate between them on some of these issues.

One of the huge puzzles about the Public  Inquiry is that the coding officer who had been employed to sort out the coding issues in the trust in 2007 was never called as a witness. What is even more surprising is the discovery that she would have liked to have been called.  This article begins to explore the story behind the Mid Staffs mortality rates.

The following article gives us some useful background information to the level of deaths and it is shows us in the second graph a dramatic representation of what happened to HSMR in Mid Staffs during the period in question. If read in conjunction with the coders story this begins to make perfect sense.

The debate is really only just beginning. We are currently seeing 14 hospitals under investigation because of their mortality rates, and the suspicion by many is that this is tied in with the plans to downgrade smaller hospitals. 

There is a whiff of conspiracy theory and talk of making it a criminal offence to falsify mortality data. If we look at what actually happened in Mid Staffs, and the shortage of skilled coders in the country then this looks like a massive red herring.  It may be worth looking at other possible causes for variation of data quality before calling in the police!

This letter from Professor Black  politely but firmly makes a point with relation to Mid Staffs.   

As Robert Francis made clear in his first report: "It is in my view misleading and ... a potential misuse of the figures to extrapolate from them a conclusion that any particular number, or range of numbers, of deaths were caused or contributed to by inadequate care." Some patients experienced appalling care for which those responsible must be accountable. But for politicians and journalists to repeatedly claim the actions of staff caused what would amount to the largest corporate manslaughter in modern times is unjustified