Lessons from loss

The content discussed in this episode may be specific to the guests' organization or location and may not be applicable to other organizations, states, territories or countries. The material presented in this podcast is for general information purposes only and should not be considered health, legal, or financial advice.

Medical administration is a rewarding profession, but it comes with challenges. So what is it like and what should you do if confronted with a monumental administrative difficulty? This is the podcast that takes unfortunate scenarios and explores the essentials of clinical governance to find solutions. I'm Dr. David Rankin. A very experienced medical administrator and lead fellow with the Royal Australasian College of Medical Administrators. And this is Safeguarding. The essentials of clearing.

Today, lessons from loss. The reality is there are weights to get to experts depending on where you live. That's Dr. Liz Mullins, the Director of Medical Services at Beeger Valley Health, in southern New South Wales local health district. And I'm presenting her with a difficult scenario. What was the quality of the patient's death? What did we do in terms of looking after the patient before they died? In this scenario, you receive She died of a catastrophic stroke in the emergency department.

The patient had presented to the ED three weeks earlier with symptoms suggestive of a TIA and was referred for review at the Neurology Outpatient Clinic. There was a four-week wait time for urgent cases to be seen by a neurologist. The partner alleges that the ED doctor did not appreciate the seriousness of the TIA. that the medication that they prescribed was inappropriate, and the delay of four weeks for the outpatient appointment was way too long to have to wait.

I start off by asking Dr. Mullins just what concerns the scenario raises. I think David it's one of those challenges of working in a public system. uh where the reality is there are weights to get to experts. Depending on where you live, you may not even be able to see them in your own town. so that this is a common situation, unfortunately, in terms of delays and obviously very tragic for this family. I think...

The incident raises that reality, but also what is our response to be able to mitigate those known risks? So uh what does urgent mean? Does urgent mean four weeks? Does urgent mean I pick up the phone and I ring my mate who runs the neurology clinic and say, I'm very worried about this and can they get in earlier? The contrast is obviously in the private sector where that is exactly what would happen. Someone would be wrung and they'd be fitted in.

The heart of this complaint, though, is that the patient died. Tragic death. How do you determine which deaths the hospital should be reviewing? So I work in New South Wales and New South Wales is extraordinary in many ways, but they have invested substantially in processes to try and really learn. The Clinical Excellence Commission has a number of processes and systems. to allow us to really try and learn and one of them is the mandatory death order.

So I would meet with the family and I would go about then finding under our own local systems what had happened or what opportunities were there. But for the death itself, it would be recorded in the death audit. The death audit is very clear and comprehensive. It goes through the causes of death, the contributing factors. It then very importantly looks at end-of-life planning, not so much in this case.

But what was the quality of the patient's death? What did we do in terms of looking after the patient before they died? Now in this situation I'm assuming that this would have gone to the coroner and there's a process around notification to the coroner. Explaining that to the family can be very difficult because there can be some delays.

but usually no more than about a week in my jurisdiction, because that obviously delays the funeral. So there are a number of ways in which deaths get looked at, but certainly in New South Wales Any DOA gets reviewed under the death audit if they've come to the emergency department. So there's a very clear process with a focus on learning.

Liz each death provides different opportunities for learning. There's the death of the patient that's been in palliative care for some months and their death is expected and effectively imminent. On the other hand, there's deaths that occur in ICU or deaths that occur immediately after surgery, which are tragic, unexpected, and often highly preventable. How do you sort of grade the the type of review that you undertake? So those ones are the ones that I know about.

So I'm not informed about every death in the hospital as the case you gave, ICU, post surgery, whatever. So they are then looked at immediately by our team. We use the scrum all the time, but we get together and I review the medical record. Firstly, I will then always speak to the doctors involved to see how they are, but also to find out exactly what happened. If it's a very serious notifiable death, obviously the coroner's involved.

If it would fall into the category of a Severity Assessment Code 1 or a Sentinel Event or a SAC 2, then that goes to clinical governance and that would also be reviewed as part of their processes. The good thing about the death audit system is that all those other deaths that happen that are expected are looked at and from time to time we will get a death where I'll be looking at it or if one of the nurses is reviewing it will bring it to me and say, Hmm.

That seems a bit quick. They're on a morphine pump and they've died. Now that may be entirely appropriate, but it on face value looks a bit quick. And so that's where the the death audit screening, if you like, will raise those deaths that you might not know about and are important to know about.

How do you go about a death review when multiple parties are involved? You may have the GP, the community nurse, the hospital, the E D l lots of teams could all take responsibility. In this case we've got a patient that was seen in the emergency department but doesn't seem to have talked to their GP about getting some faster review by neurology. So how how do you undertake a review when multiple parties are involved? Well it actually just takes the legwork of speaking to them.

And depending on where people work, their clinical governance unit will do that. I work in a relatively small hospital, just a hundred beds in a rural setting, so I'm very hands-on around that, and I almost always know the people involved. And so me asking them to comment on a case or provide an explanation is not unusual for them.

I think one of the challenges in larger hospitals is that it's uh someone ringing a doctor or a junior doctor whom they don't know, saying they're from the clinical governance unit that they might not know who that or what that is. saying, Could you tell me about your involvement in a case that resulted in a death? And not unsurprisingly that will make people very defensive.

So I think it's very important that if you are going to be speaking to a number of people, there's already a culture where they understand who's speaking to them and why and that I see this and I know directors of medical services are awfully busy. But they or their registrars need to be the people I think to reach out to those doctors to explain that they're going to get a call from someone. We've already chatted about it and we're just trying to, as you can imagine, find out the fact.

and obviously provide some feedback to the family who are not surprisingly very upset about it all. And if there is in fact someone has made a mistake, they've made a misdiagnosis they haven't followed up on some critical symptoms, then that's gotta be done as a learning opportunity for that doctor. And then through an M M model to be able to de-identify a case, but then say, okay, so in this case, was it clearly a TIA? Was it not a TIA? Is it acceptable a TIA waits for four weeks?

What was the age of the patient? If they were forty eight, if they were eighty eight, does that change what we do? And then I think we need to look at that model where you can get Just as going to a GP, they have urgent slots left every day. Do we have any slots left in our outpatient services? for patients who need to be seen within a week. And so that becomes the system learning and also the learning for the individual doctor and the department.

We can review the technical cause of death or the delivery or non delivery of care, but so often what's important is the quality of death. How do you ensure that your death reviews include this element of the quality of death and support? As I said, and I'm uh I'm not being paid by New South Wales Health, but under their death audit, which I suggest people use, there are questions in relation to end of life planning.

So were these people known to palliative care? Were the admitting staff able to access palliative care? And so that idea of setting people up to know what's going on. And we've all been involved in awful situations. I remember some years ago a lovely family were in that wife and husband of his brother.

and they weren't actually on the medical ward, so they're on a surgical ward, so it's slightly different. And he was clearly, clearly dying. I'm not sure that anyone had used that word with the family. And so about eleven o'clock at night they went home and he died at two o'clock in the morning. Now they were distraught because as she said to me, we could so easily have stayed. You mentioned that this case would go to the coroner.

The coroner's role is to investigate the cause and basis for death. Is that a duplication of investigation? Should the hospital back off and wait until the coroner's report comes out or should the hospital do their own investigation in parallel? This is possibly a trick question, David. I am I am an interventional director of medical services.

I need to have a sense of whether we're in trouble or not. And I need to know that before I'll wait for a coroner. Now, usually a coroner will send a report which will give a cause of death. So in this case if it says it's a significant stroke, then that's important. If it says, you know, they had a brain tumour and they had a bleed and no one knew about it, then that's something else. So I always need to find out in the short term how my staff are.

But B is there anything I need to do from a system intervention point of view before I wait for a formal review either from clinical governance or from the coroner or or anyone else? I always find it extraordinarily helpful to call and see if you can talk to the medical examiner at the coroner's office and just find out what their findings were. The the formal coroner's report can take years sometimes to come out.

Uh but the medical examiner's reports can be extraordinarily helpful in your own investigation. And David I say they're very helpful. We had one recently. I know what the patient died of and that's very important in terms of communicating with the family and our staff, et cetera. But that process has improved a lot in my experience recently.

So how much information do you share with the partner of this patient that's died? So there is clearly an obligation under open disclosure legislation policy to share. I've done a lot of open disclosure and there's no doubt that honesty is important. I think what you need to be able to do is speak to the clinical governance unit together and say, this is what we now know.

This is what we're doing. There's going to be a thing called a root cause analysis that's going to take 90 days. We're going to find some information around that. But I think it's very important to share facts as you know them because there's always an element of guilt in situations like this.

where the partner will think, well they said it was four weeks and I didn't make a fuss and I didn't try to get in earlier and would that have made a difference? So I think we have to be very mindful and empathetic. To families who often feel great grief as well as sadness and loss. that they might or should have done something more. And I think if we can assuage that, I think that's important, as well as saying, this is what the result says.

But you can't unilaterally go off and do that. Even the most senior medical administrator has to speak to the clinical governance unit and get the OK for that level of frankness. Now uh medical defence organisations are supportive of people being franked And increasingly and for some time the hospital insurers, however they're structured, are also supportive of open disclosure. But you would just want to let people know what you are saying that that's okay to do that and then proceed.

But honesty is absolutely the best policy in relation to engaging with families. One of the observations from medical staff is that the clinical governance unit often doesn't tell them the outcomes of their investigations when they're investigating one of their patients. So the clinical governance unit does its death order, makes a couple of observations, but doesn't include the clinicians that were involved in the patient's care. How do you go about making sure that the clinicians are informed?

You know, it's interesting, David. I'm often astounded, not so much in my place, but in other places where clinicians don't even know they've been involved in a complaint. you know, they'll see the patient in their room six weeks later and they'll say, Oh, how are you? And the patient you know, fit to be tired, saying, What do you mean, how am I? Did you not know what happened while I was in hospital or

or what have you and then the clinician just feels stupid. So particularly in a VMO system where they're not on site all the time, you absolutely need to let them know there's been an incident involving their patient. There's been a complaint involving their patient, even if it's nothing to do with them.

And obviously, if a case is being reviewed as a result of a death audit, to let them know, but not just to let them know, to ask them why the documentation is saying this and is that what happened or what you intend. you need to make sure that there are very good processes in place'cause these are beyond an individual DMS's role. It's a very important part of our conversation. The other side of that is informing doctors that patients that they've treated in the past have now died.

So the sort of scenario is a patient is under respiratory physicians, develops a nodule in their lungs, cardiothoracic surgery operates, goes back to the respiratory physician, then goes into palliative care and dies six or twelve months later. The cardiothoracic surgeon and even the respiratory physician may not be aware that the patient has died. It can be embarrassing for them, running follow ups with the patient's relatives to be told.

Should the hospital be trying to inform the clinicians that have been involved in patients care that the patients died? I think that's a very insightful observation, David. I find it difficult for us to let GPs know a patient's died who's an inpatient. I'm gonna have to make sure on Monday that the systems I think are in place are are in place. And I think there's a very good argument because we are able to find out the doctors involved.

that we should be able to send them a note about that. I don't think it currently happens, but I think it's a very reasonable thing to do, particularly when the rooms ring and say to Mrs. Nguyen, you know, your husband's appointment with doctor so and so for six months, you know, would you be free next Thursday? Can be awful for the people uh who are behind.

But I think that's a really good idea and I'll I'll have to look and see what I can do on Monday. The other side of death is the staff that looked after the patient during their final episode.

How do you provide support to them? And they do need support. Older people, people who've had a lovely full life are different to a thirty eight year old, you know, mother of three. As you get further and further out from tertiary centres

then these patients will be managed in a general ward, for example in a small hospital. There are surgical patients, medical patients. Now there's probably a a single room where palliative care patients go, but I do think for those wards that don't do this routinely, we do need to make sure that palliative care come and speak with them regularly, that they come and not only manage the patient but the staff.

But I think that's where the biggest gap will be. And the other thing is of course to let the GPs know that there'll be a deterioration, many of whom have looked after these patients. For a very long time they may not necessarily be able to come in, but they're always grateful to know what's going on. And the bigger the hospital that is, the harder the challenge is to make sure those little niceties get done. And I think that's a challenge for all of us.

There's a real role for pastoral support as well in helping the staff move through their grievance process. One of the issues many hospitals have is the concept of a chapel seems to be going out of favour. So there's no quiet space near the emergency department or on a medical ward where relatives and pastoral support staff and hospital staff can meet together and just

meditate on the death of a person that's died. We're very lucky. I work in a hostel was opened in 2016. There's a lovely space. It's called the Quiet Space. And in fact sometimes we do our open disclosure in that space because it It's a nice space that is very quiet. There's almost no one in there. And I've certainly had difficult conversations with doctors or, you know, who need some help and support to go in there.

I think in old bills there's always been a spot. It was probably called the chapel. And it's often been, you know, retitled as the quiet room. But I think in most places there is probably somewhere where you can go. If you come to a new place, it's often worth asking where is a quiet space? Because it's not just for families, as you said.

Often in ICU there's a quiet space because they're relatively newly designed. But I do think depending on where your office is you may need quiet space to talk to a colleague. But if you're not sure where they are, I'd certainly try and find them. I think that's really important is yeah, making sure that the environment's appropriate to the conversation. Wards can be extraordinarily busy and noisy and and distracting. But also we we don't notice that noise.

You know, and so to put yourself in their position. Sometimes when I have to speak with families after something awful has happened, I will almost always offer to meet them in their home. And that's because many people don't want to come back to the hospital, certainly not in the short term.

And to say, well, we're going to do an open disclosure with you, so please come back to the place where your most important person in the world died and we actually contributed to it is not a setup for any form of meaningful, empathetic conversation. and sometimes we do it with the G P, sometimes we'll do it in a coffee shop where they're comfortable. But I do think so acutely it should be on site. But when people often want to revisit what's happened and sometimes

That will take people some months. They see a case on television, they watch a scenario in a television show. And I'd not probably two or three times a year will get someone say, Is that what happened to Mum do you think? You know, I've heard of flesh eating bacteria. Was that was what was wrong with mum. And they've had months to sort of process it, but then they've actually got the space in their mind to ask questions that they didn't think to ask.

at the time and that can be very important in their healing because so much of things have been unresolved, despite us thinking we've done very well at explaining things at the time. I think there's a real temptation as well to use electronic media, but it's not possible to reach out and touch a person on Zoom or Teams, particularly the initial couple of meetings where you're establishing trust and rapport and communication.

Yeah. I mean th the challenge and and I view most things now through the prism of rural and regional Australia is that it's tempting, but in fact I've met with people halfway between the hospital and their home. in a quiet coffee shop to have that conversation. And it's just from, you know, doing this for a long time and speaking to people, they are always enormously grateful that senior people have taken the time to come and explain things to them where they're not rushed.

and sometimes you feel you're repeating things over and over again. But their understanding of what's happened is so important for their long term mental health and and to be able to grieve properly. So I would certainly concur that face to face is absolutely the best.

So what criteria do you use? Coming back to this initial question, Which deaths do you spend the time over and which deaths do you just do the tick box audit on? How do you personally set criteria for which deaths you're going to get involved in as the DMS? Listeners to this podcast will know of Paul Nassell, who was one of the giants of the medical defense organizations in this country. A remarkable man, a very, very talented GP and an expert.

in medical defence matters. And he had a very simple criteria. And I can't use the actual word he used. But he said, when you get a phone call and you say to yourself, hmm, rubbish happens. And then you get a phone call and you'll say Holy rubbish. And the holy rubbish is the one where you open the medical record, get down to where they are, and really take steps to understand it. And so that's that's a very blunt, but I think very effective tool I have used my professional life.

to be able to distinguish with the things you need to take action about. And it may be that everything's fine, there's nothing to see here, it's all okay. And often the person who rings you has sort of got half of the story and not all the story and all that kind of stuff. I think the thing about having a death audit rather than it being seen as a tedious bureaucratic process means that every death is looked at.

Thank you, Liz. Great discussion. Bringing in the other people involved in a death audit process. It's not just the patient or the survivors. It's the staff, the doctors involved. And that emotional impact. Of everybody. I think you're absolutely right. I think the forgotten people in all of this are the GPs.

And I know in in Metro Centres people don't necessarily have their own GP like they do in the country where, you know, Doctor So and so has looked after me and my family and and that's one of the tragedies of rural general practice. But I think there's a professional courtesy as well as an understanding that they are their patients for far more of the time than they've ever been our patients.

And so I think we need to do much better to make sure we send them that information. But I think in our busyness of acute hospitals, you know, focusing on all the terribly important things we do, we forget that there are

practitioners that have looked after these people for a very long time and certainly when they've been through a difficult time we need to let them know, as I said, as a professional courtesy, but just so that they're aware, particularly as they're going to be looking after other members of their family. Thank you, Liz. Great discussion on the utility and purpose and function of death audits in our system. Pleasure.

That was Dr. Liz Mullins, the Director of Medical Services at Beagle Valley Health, in the southern New South Wales local health. And that brings us to the end of this episode of Safeguarding Healthcare. I'm Dr. David Rankin. Follow Safeguarding Healthcare free on Apple Podcasts, Google Podcasts, Spotify, or wherever you listen to podcasts. This podcast is produced by Sound Cartel for the Royal Australasian College of.