Prevent deaths by reporting medical errors urges BMJ study

A study published by the British Medical Journal estimates that medical error is the third biggest cause of death in America, after heart disease and cancer. Medical error could be responsible for more deaths than respiratory (lung and chest) diseases.

If we considered medical error alongside other diseases, it would come third in the leading causes of death in America. We should also be concerned on this side of the pond, because the study notes that medical error leading to the death of a patient is underestimated in the UK.

What medical mistakes can cause the death of a patient?

Two examples of medical errors which can lead to the death of a patient are

  • Internal bleeding  following surgery which when had not been recognised in time to repair the injury;
  • Confusion over the type of medication a patient is to receive (so that they are given the wrong one) or with the dose that should be given (not enough or too much).

Case study

The report in the BMJ gives an example of a young woman who died after medical tests were carried out on her to investigate a non-specific health complaint following a successful transplant operation. One of the tests, which was found to have been carried out unnecessarily, involved putting a needle into the space around her heart. She died days later; the cause of death was listed as cardiovascular. However, a post mortem examination revealed that the needle inserted during the investigation grazed her liver causing an injury that resulted in subsequent rupture and death.

In the above case the cause of death on the death certificate was misleading.

Can better reporting reduce deaths from medical error?

The report makes a number of suggestions to reduce the number of deaths from medical error. These included adding a box on the death certificate to say whether the person died of a preventable complication related to their medical care. It also proposes that hospitals carry out an investigation into causes of death to determine the potential contribution of error. The report suggests that by recording deaths where medical error was a contributing factor more accurately, the medical profession can use this information to design safer systems and hopefully prevent deaths.

Information provided on the death certificate

It is very important that doctors provide clear, accurate and complete information about the diseases or conditions that caused the death, in accordance with the guidance provided by the Office for National Statistics’ Death Certification Advisory Group.

When recording the cause of death, the doctor is required to start with the immediate, direct cause of death. They must then go back through the sequence of events or conditions that led to death, until reaching the one that started the fatal sequence. They are also required to record any other diseases, injuries, conditions, or events that contributed to the death.

If the death is to be registered without referral to the coroner then “natural causes” cannot be recorded as a cause of death, without specifying any disease. Also, terms such as “cardiac arrest” and “respiratory arrest”, which do not identify a disease or pathological process, will not be accepted as the only cause of death. However, the current death certificates do not have a specific field where doctors are required to record whether medical error contributed to the cause of death.

Enquiry into the cause of death

In England and Wales, registrars of births and deaths are legally bound to report certain types of deaths to the coroner before the death can be registered. These include deaths occurring during an operation, or before full recovery from an anaesthetic.

A death must be investigated by a coroner if the cause of death is unknown. The coroner may order a post mortem. Where it has not been possible to determine the cause of death by the post mortem and other enquiries the coroner will hold an inquest.

Switalskis are acting in a claim where a man died after hip surgery. The doctor certifying the death  at the hospital recorded the cause of death as “stroke” without any other information. The doctor explained to the widow that if anything else was put on the certificate there would have to be a post mortem or inquest. The doctor said that this could take a long time and he did not want the widow to have to go through that. After receiving instructions Switalskis reported the details to the coroner. The coroner has now confirmed that there should be an investigation into the death, even though the death was 15 months ago.

If you think that the death of a loved one may have been caused by medical error or mistake you should seek legal advice. Switalskis expert Medical Negligence team can help you with this, and can offer advice and assistance if the coroner decides to hold an inquest.

Contact the Medical Negligence team on 0800 1380458 or send us a message using our contact form and we will call you back.

Disclaimer: The contents of this article are for the purposes of general awareness only. They do not purport to constitute legal or professional advice, and the law may have changed since this article was published. Readers should not act on the basis of the information included and should take appropriate professional advice on their own particular circumstances.

Jim Gladman

Jim Gladman is a solicitor within our Clinical Negligence team in Huddersfield and specialises in Medical Inquests. He joined Switalskis in January 2010 and has over twenty years' experience in Clinical and Medical Negligence claims. Jim's profile