Excess Deaths (Again)


I had hoped I had written enough about this but yet again we get the use of “excess deaths” – a meaningless term – but one used over and again, often by those parts of the media eager to rubbish our NHS.  I also wish we could focus on how to keep Stafford Hospital open because of the value it can bring to the local community rather than see it sacrificed because of a history that is regularly re-written.

The hundreds of “excess deaths” we keep reading about is derived from comparisons of various standardised mortality statistics.  The use of these and what exactly they measure is controversial – since it relies on a process of coding which we know is subject to error rates as well as to gaming.  Despite this, it is asserted routinely that if a trust has a higher than average standardised death ratio (say 127) then 27% represents excess deaths.  You could equally well assert that an average trust with an average rate of 100 has 25% excess deaths over the likes of Addenbrookes with a ratio of 75.  Of course on this logic every trust should have below average death rates or it is killing patients unnecessarily.

Even if you just take the extent to which the ratio exceeds some confidence interval the argument is the same, excess deaths is meaningless.  What is useful is the concept of avoidable deaths – where a death occurs because something was done which should not have been done, or something that should have been done was not done.  In either case it has to be of sufficient seriousness to contribute directly to the death.  There have been studies into avoidable deaths and these show the rate across the NHS as a whole to be around 6%.   Such studies do not depend on coding (or other guesswork) – they are based on reviews of case notes and discussions with those responsible – and are carried out by independent (clinical not management) consultants.  So in 6% of deaths a better outcome – prolonging life by an estimated average of 18 months – was possible.

And these studies also tell as a lot about why these avoidable deaths happened.  The most common causes are incorrect or late diagnosis (possibly because no senior clinician was available at the time), prescribing errors and a collection of failures around monitoring.

In the case of Stafford Hospital nobody knows what the correct standardised mortality ratio was at the time it was subject to intervention.  It is clear from the record that coding was not being done correctly so any mortality rate was wrong.

It is also clear that the only attempt that was made to do a case note review into deaths at Stafford showed little if any evidence of unnecessary deaths.  There are no comparative cross hospital statistics about avoidable deaths so nobody knows where Stafford would have appeared.

The evidence shows clearly that in parts of Stafford there were appalling and totally unacceptable standards of care but poor care and unnecessary deaths are not the same thing. The major enquiries actually looked at a part of the hospital and it is accepted that other parts of the hospital had services of high quality.  Sadly there were, and still are, cases of poor care and avoidable deaths in hospitals.

In Stafford the evidence is that cuts in staffing levels and a reconfiguration of some wards were carried out as part of an expenditure reduction exercise.  Similar exercises to reduce expenditure (cost improvements) were also happening at every other trust in the country whether they were in the pipeline to become a Foundation Trust, already a FT or just struggling.  In Stafford the suggestion is that the risk involved in doing what many others were also doing had not been properly evaluated and the impact of changes on patients was not properly monitored. Information provided to decisions makers, regulators, commissioners and performance managers was woefully inadequate and often incorrect or incomplete.  Information that indicated problems was either discounted or offset again other information flows.

Since no evidence was taken about what happened in other hospitals I am very wary about any generalisations from what happened in one part of one small hospital.

Having studied far more than just what is in the set piece reviews I am confident that I still do not fully understand why such poor care happened and what why problems were not picked up earlier.

I am confident that a higher than average mortality ratio for one year may well be of no significance.  But some trusts have a higher ratio or higher death rate, however it is measured, year after year.  Why?  The only study I have seen to explain this is that the link is to resources.

Those hospitals which have better (relative ) levels of funding will have better death rates. Is this a surprise?