Contributors viii
Preface ix
Abbreviations x
Introduction XI
Part 1
Section 1: Errors and their causes 1
A few words about error 1
Learning from system failures – the vincristine example 1
Evidence from the NHSLA database 8
The patient consultation 10
Failure to identify a sick patient 12
Inability to competently perform practical procedures 13
Failure to check test results or act on abnormal findings 14
Prescribing errors 14
Sources of error in the case of vulnerable adults 16
References and further reading 18
Section 2: Medico-legal aspects 19
Error in a legal context 19
Negligence 19
Clinical negligence 20
Issues around consent 23
An attorney refusing treatment 27
A patient without capacity refusing treatment 27
Emergency treatment 28
Deprivation of liberty safeguards 29
Part 2 Clinical cases v
Introduction 35
Section 1: Civil liability negligence and compensation 36
Case 1 A shaky excuse 37
Case 2 Making matters worse 40
Case 3 Chase the bloods 43
Case 4 Falling asleep en-route 45
Case 5 Bad luck or bad judgement 48
Case 6 An opportunity missed 51
Case 7 Better late than never 53
Case 8 Man down 56
Case 9 Cry wolf 58
Case 10 Not a leg to stand on 60
Section 2: Unexpected death: the coronial system and clinical risk management 62
Case 11 A doubly bad outcome 63
Case 12 Difficulty with diarrhoea 66
Case 13 A flu-like illness 69
Case 14 Falling standards 72
Section 3: An approach to complaints 74
Case 15 A woman with chest pain 75
Case 16 Clumsiness 78
Section 4: Competence 80
Case 17 A change in plan 81
Case 18 Starving to death 85
Case 19 An irregular presentation 88
Case 20 Irrational but not incompetent 90
Section 5: Restraint 92
Case 21 A challenging discharge 93
Case 22 Ruling out the organic 96
Case 23 Endless wandering 99
Case 24 Can you please take these handcuffs off? 101
Case 25 Own worst enemy 103
Section 6: Miscellaneous 105
Case 26 All eggs in one basket 106
Case 27 A major mix-up 108
Case 28 Under the radar 110
Case 29 A cantankerous recluse 113
Case 30 Keep an open mind 115
Case 31 Healthcare acquired infection? 117
Case 32 Backing the wrong horse 120
Case 33 A surprising turn of events 122
Case 34 Funny turn 125
Part 3 Investigating and dealing with errors
1 Introduction 127
2 How hospitals try to prevent adverse errors and their recurrence 127
3 The role of hospital staff 132
4 The role of external agencies 134
5 Hospital investigations 137
6 Legal advice – where to get it and who pays 141
7 External investigation of errors and incidents 143
8 The role of the doctor 160
9 Presenting oral evidence 162
10 Emotional repercussions 164
11 Conclusion 164
References 164
Index 167
