Everyone makes mistakes. And as healthcare professionals we make mistakes as well.
Some mistakes are small, some mistakes are serious. Some serious mistakes are a system error rather than an individual doctors mistake. I am going to explain all mistakes from a low intensity to the worst case scenarios in this blog post.
DATIX
This system is to identify any preventable errors in the work place.The person who has identified such issues has to fill in a form online and then submit it.
Datixes can range from :
1. Fall on the ward - the nurses usually fill it
2. Drug error - any one can do it. Usually the pharmacists are good at doing this.
3. Patient care - an inappropriate CPR
4. Bullying - some trusts have this option as well.
MYTHS ABOUT DATIXES
A Datix is against an individual.
Datixes are done to identify the root cause behind an incident. This does not mean that the person behind this is you and that the person filling this form has a grudge against you.
Some colleagues use the term ' This person was datixed' - That is wrong terminology.
The 'handler' of the Datix (ie the person whom this report goes to) reviews the form, looks in the patients notes and then identifies anything the trust can improve on.
A few examples
A lot of Datixes from a ward where patients are falling at night
The handler ( who in this case might be the matron) will review the forms, see which patients were involved and how they can improve the management to avoid this.
The matron will then present these cases in the monthly management meeting ( morbidity and mortality meeting / clinical governance meeting, etc) and see how they can prevent- small measures like the following can help:
1. Ensuring the nursing team is well staffed on the ward
2. Patients at high risk of falls are identified at every handover.
3. The HCAs do their round more regularly when looking after such patients.
4. Equal distribution of patients at risk of falls allocated to HCAs
5. Minimum number of high risk patients per HCA/nurse on the ward identified.
Things like this can help prevent falls.
Now was this Datix against anyone? No! This way, the ward was able to identify issues , the management was made aware and it was their duty to find a solution.
A doctor has been mentioned in a Datix. This means it is serious.
This, like above can be a systemic error.
For example:
Incorrect prescription of gentamicin picked up by the pharmacist who then filled a Datix form.
this datix was reviewed by the head pharmacist and it was discussed in the clinical governance meeting. The microbiology team and pharmacists decided to make a gentamicin chart/ improve the current chart so that doctors prescribing gentamicin knew what doses to prescribe.
As you can see, the doctor was not blamed. The system was like that and this way, they improved the prescribing guidelines.
I hope this clears any confusions about Datix
CORONER REFERRAL
Patients whom are admitted to hospital/pass away in the community and the cause of death/sequence of events leading to death is not clear are referred to the coroner.A few other cases mentioned here are also referred:
https://gpnotebook.com/en-gb/simplepage.cfm?ID=530186303
The coroner then reads through the information given to them and decides whether a post mortem is warranted.
If a post mortem is warranted, the pathologist performing it reports their findings which are sent to the coroner and they review it.
If the cause is not clear, individuals involved might be asked to provide a statement.
Anyone can be asked to provide a statement - nurses, doctors, family members, carers, anyone involved with the patients care whom the coroner thinks is relevant.
If the coroner wants a statement from healthcare professionals working in a hospital, the hospitals legal team is contacted and the individuals who were directly involved in the patients care are asked to provide a statement.
The trusts legal team then gets the notes of the patient and an internal investigation is opened - led by a consultant. The consultant goes through the patients notes and then writes up a report which mentions the doctors involved.
The doctors ( if involved) then contact their indemnity insurance team and let them know. They read through the notes and make a statement based on factual documented evidence.
The statement is then sent to the trusts legal team and once they are happy, it is sent to the coroner.
The coroner reviews these statements and then may either decide to close the case or hold an inquest.
In an inquest, the relevant health care professionals give their statements. The family is also present. These sessions are recorded and sometimes the local press can be present.
After the inquest, the coroner gives their verdict:
1. Criminal negligence
2. Self referral to the GMC
3. The case is closed.
So in summary,
If you are a doctors involved in a patients care,
1. A coroner referral DOES NOT mean you will have to give a statement
2. Giving a statement DOES NOT mean you will have to attend an inquest
3. Being asked to attend an inquest DOES NOT mean you will be arrested for manslaughter/lose your license.
Here are some tips:
1. Document like you are going to present these findings in court. Hence in the NHS, documentation is key. If it was not documented, it did not happen
2. Discuss things you are not sure about as a FY1/SHO with your registrar/consultant
3. Document any conversation you have had with them.
4. Have indemnity insurance
http://omarsguidelines.blogspot.com/2017/08/indemnity-insurance-for-imgs.html
5. Do not panic - as mentioned above :
A coroner referral DOES NOT mean you will have to give a statement
Giving a statement DOES NOT mean you will have to attend an inquest
Being asked to attend an inquest DOES NOT mean you will be arrested for manslaughter/lose your license.
6. ALWAYS consult your medical indemnity team for any advice - NEVER give statements WOTHOUT consulting them.
7. Inform your supervisors about this event
8. Be careful with regards to reflecting - if you have to reflect, copy paste the statement you have given.
9. Safety netting is here for a reason - sometimes things are missed by the triage team, ED doctors, clerking SHO, registrar doing senior reviews and sometimes even the post take consultant and subsequent ward reviews by FY1s to consultants.
10. Mistakes happen - it is important to be open about them.
11. NEVER lie. Never try to change any documentation.
12. A lot of medical professionals from GPs to consultants have to attend inquests - although it is highly stressful as you never know what is going to happen, talking about it helps.
13. Having good relations with the management and consultants helps. They will support you if the need arises.
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