HSIB: deaths from deterioration

An investigation from the HSIB has concluded that a national approach is needed in order to tackle the recognition and response to deteriorating patients.

In its latest report, the Healthcare Safety Investigations Branch (HSIB) shines a critical light on the management of acutely ill, deteriorating patients in hospital.

HSIB carried out an investigation into the death of a patient who was admitted to hospital with severe abdominal pain two weeks after emergency surgery for a perforated duodenal ulcer. She had been admitted to an emergency department and had regular observations of her vital signs, and was given intravenous fluids when her blood pressure dropped.

Some eight hours after her admission she was eventually transferred to the surgical ward, and while there her condition deteriorated further. She required active resuscitation and was admitted to the intensive care unit, but sadly died despite the resuscitative measures. A post-mortem revealed that the cause of death was shock secondary to small bowel obstruction, which occurred secondary to adhesions.

HSIB recommendations

HSIB recommended that the national approach that was being developed to address preventable death from sepsis be expanded to include the deteriorating patient, such as the incident investigated. It also noted the difficulties that arise with situational awareness and its impact on decision-making. Although difficult to address, HSIB suggested that systems needed to be designed to ensure information (and therefore awareness) gets to the people and places it should.

A further recommendation was aimed at strengthening the use of the Royal College of Physicians' National Early Warning Score Two (NEWS2) in practice, and in particular its application to different care settings. This should help to ensure greater consistency and accuracy in identifying when a patient's condition was getting significantly worse, to indicate they may need treatment such as resuscitation.

Hospital doctors will recognise the need to respond promptly and appropriately to the clinical signs suggesting that a patient is deteriorating, and most may want to reflect on the HSIB's report's findings.

This guidance was correct at publication 28/05/2019. It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.

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