Ian P. Reckless is Consultant Physician and Assistant Medical Director, Oxford University Hospitals NHS Trust D. John M. Reynolds is Consultant Physician and Clinical Pharmacologist, Oxford University Hospitals NHS Trust Sally Newman is a Solicitor and Head of Legal Services, Oxford University Hospitals NHS Trust Joseph E. Raine is Consultant Paediatrician, Whittington Hospital, London Kate Williams is Partner, RadcliffesLeBrasseur Solicitors, Leeds Jonathan Bonser is Consultant in the Healthcare Department of Fishburns LLP, Solicitors, London, and former Head of the Claims and Legal Services, Department of the Leeds office of the Medical Protection Society

• Contributors  viiiPreface  ixAbbreviations  xIntroduction  XIPart 1Section 1: Errors and their causes 1A few words about error 1Learning from system failures – the vincristine example  1Evidence from the NHSLA database 8The patient consultation 10Failure to identify a sick patient  12Inability to competently perform practical procedures 13Failure to check test results or act on abnormal findings  14Prescribing errors 14Sources of error in the case of vulnerable adults 16References and further reading  18Section 2: Medico-legal aspects 19Error in a legal context 19Negligence  19Clinical negligence 20Issues around consent 23An attorney refusing treatment 27A patient without capacity refusing treatment 27Emergency treatment 28Deprivation of liberty safeguards 29Part 2 Clinical cases vIntroduction  35Section 1: Civil liability  negligence and compensation  36Case 1 A shaky excuse 37Case 2 Making matters worse 40Case 3 Chase the bloods  43Case 4 Falling asleep en-route 45Case 5 Bad luck or bad judgement 48Case 6 An opportunity missed  51Case 7 Better late than never  53Case 8 Man down  56Case 9 Cry wolf 58Case 10 Not a leg to stand on  60Section 2: Unexpected death: the coronial system and clinical risk management 62Case 11 A doubly bad outcome 63Case 12 Difficulty with diarrhoea  66Case 13 A flu-like illness  69Case 14 Falling standards  72Section 3: An approach to complaints  74Case 15 A woman with chest pain  75Case 16 Clumsiness  78Section 4: Competence 80Case 17 A change in plan  81Case 18 Starving to death 85Case 19 An irregular presentation  88Case 20 Irrational but not incompetent  90Section 5: Restraint 92Case 21 A challenging discharge  93Case 22 Ruling out the organic 96Case 23 Endless wandering 99Case 24 Can you please take these handcuffs off?  101Case 25 Own worst enemy  103Section 6: Miscellaneous  105Case 26 All eggs in one basket  106Case 27 A major mix-up  108Case 28 Under the radar  110Case 29 A cantankerous recluse  113Case 30 Keep an open mind  115Case 31 Healthcare acquired infection?  117Case 32 Backing the wrong horse  120Case 33 A surprising turn of events  122Case 34 Funny turn  125Part 3 Investigating and dealing with errors1 Introduction  1272 How hospitals try to prevent adverse errors and their recurrence  1273 The role of hospital staff  1324 The role of external agencies  1345 Hospital investigations  1376 Legal advice – where to get it and who pays  1417 External investigation of errors and incidents  1438 The role of the doctor  1609 Presenting oral evidence  16210 Emotional repercussions  16411 Conclusion  164References  164Index  167

“My experience as an expert witness in clinical negligence cases, MPTS Panel chairman, medical adviser to a Public Inquiry and as a sometimes commissioned independent reporter on adverse incidents tells me that these are excellent books, valuable for all clinicians, not just those in high-risk specialties; and all NHS managers involved in maintaining or improving the quality of care. The case vignettes, alone, are useful source material for teaching medical trainees on what can go wrong and how to deal with it when it does.” (Harvey Marcovitch, Clinical Risk journal)

Ian P. Reckless is Consultant Physician and Assistant Medical Director, Oxford University Hospitals NHS Trust D. John M. Reynolds is Consultant Physician and Clinical Pharmacologist, Oxford University Hospitals NHS Trust Sally Newman is a Solicitor and Head of Legal Services, Oxford University Hospitals NHS Trust Joseph E. Raine is Consultant Paediatrician, Whittington Hospital, London Kate Williams is Partner, RadcliffesLeBrasseur Solicitors, Leeds Jonathan Bonser is Consultant in the Healthcare Department of Fishburns LLP, Solicitors, London, and former Head of the Claims and Legal Services, Department of the Leeds office of the Medical Protection Society

• Contributors  viiiPreface  ixAbbreviations  xIntroduction  XIPart 1Section 1: Errors and their causes 1A few words about error 1Learning from system failures – the vincristine example  1Evidence from the NHSLA database 8The patient consultation 10Failure to identify a sick patient  12Inability to competently perform practical procedures 13Failure to check test results or act on abnormal findings  14Prescribing errors 14Sources of error in the case of vulnerable adults 16References and further reading  18Section 2: Medico-legal aspects 19Error in a legal context 19Negligence  19Clinical negligence 20Issues around consent 23An attorney refusing treatment 27A patient without capacity refusing treatment 27Emergency treatment 28Deprivation of liberty safeguards 29Part 2 Clinical cases vIntroduction  35Section 1: Civil liability  negligence and compensation  36Case 1 A shaky excuse 37Case 2 Making matters worse 40Case 3 Chase the bloods  43Case 4 Falling asleep en-route 45Case 5 Bad luck or bad judgement 48Case 6 An opportunity missed  51Case 7 Better late than never  53Case 8 Man down  56Case 9 Cry wolf 58Case 10 Not a leg to stand on  60Section 2: Unexpected death: the coronial system and clinical risk management 62Case 11 A doubly bad outcome 63Case 12 Difficulty with diarrhoea  66Case 13 A flu-like illness  69Case 14 Falling standards  72Section 3: An approach to complaints  74Case 15 A woman with chest pain  75Case 16 Clumsiness  78Section 4: Competence 80Case 17 A change in plan  81Case 18 Starving to death 85Case 19 An irregular presentation  88Case 20 Irrational but not incompetent  90Section 5: Restraint 92Case 21 A challenging discharge  93Case 22 Ruling out the organic 96Case 23 Endless wandering 99Case 24 Can you please take these handcuffs off?  101Case 25 Own worst enemy  103Section 6: Miscellaneous  105Case 26 All eggs in one basket  106Case 27 A major mix-up  108Case 28 Under the radar  110Case 29 A cantankerous recluse  113Case 30 Keep an open mind  115Case 31 Healthcare acquired infection?  117Case 32 Backing the wrong horse  120Case 33 A surprising turn of events  122Case 34 Funny turn  125Part 3 Investigating and dealing with errors1 Introduction  1272 How hospitals try to prevent adverse errors and their recurrence  1273 The role of hospital staff  1324 The role of external agencies  1345 Hospital investigations  1376 Legal advice – where to get it and who pays  1417 External investigation of errors and incidents  1438 The role of the doctor  1609 Presenting oral evidence  16210 Emotional repercussions  16411 Conclusion  164References  164Index  167

“My experience as an expert witness in clinical negligence cases, MPTS Panel chairman, medical adviser to a Public Inquiry and as a sometimes commissioned independent reporter on adverse incidents tells me that these are excellent books, valuable for all clinicians, not just those in high-risk specialties; and all NHS managers involved in maintaining or improving the quality of care. The case vignettes, alone, are useful source material for teaching medical trainees on what can go wrong and how to deal with it when it does.” (Harvey Marcovitch, Clinical Risk journal)

Ian P. Reckless is Consultant Physician and Assistant Medical Director, Oxford University Hospitals NHS Trust D. John M. Reynolds is Consultant Physician and Clinical Pharmacologist, Oxford University Hospitals NHS Trust Sally Newman is a Solicitor and Head of Legal Services, Oxford University Hospitals NHS Trust Joseph E. Raine is Consultant Paediatrician, Whittington Hospital, London Kate Williams is Partner, RadcliffesLeBrasseur Solicitors, Leeds Jonathan Bonser is Consultant in the Healthcare Department of Fishburns LLP, Solicitors, London, and former Head of the Claims and Legal Services, Department of the Leeds office of the Medical Protection Society

• Contributors  viiiPreface  ixAbbreviations  xIntroduction  XIPart 1Section 1: Errors and their causes 1A few words about error 1Learning from system failures – the vincristine example  1Evidence from the NHSLA database 8The patient consultation 10Failure to identify a sick patient  12Inability to competently perform practical procedures 13Failure to check test results or act on abnormal findings  14Prescribing errors 14Sources of error in the case of vulnerable adults 16References and further reading  18Section 2: Medico-legal aspects 19Error in a legal context 19Negligence  19Clinical negligence 20Issues around consent 23An attorney refusing treatment 27A patient without capacity refusing treatment 27Emergency treatment 28Deprivation of liberty safeguards 29Part 2 Clinical cases vIntroduction  35Section 1: Civil liability  negligence and compensation  36Case 1 A shaky excuse 37Case 2 Making matters worse 40Case 3 Chase the bloods  43Case 4 Falling asleep en-route 45Case 5 Bad luck or bad judgement 48Case 6 An opportunity missed  51Case 7 Better late than never  53Case 8 Man down  56Case 9 Cry wolf 58Case 10 Not a leg to stand on  60Section 2: Unexpected death: the coronial system and clinical risk management 62Case 11 A doubly bad outcome 63Case 12 Difficulty with diarrhoea  66Case 13 A flu-like illness  69Case 14 Falling standards  72Section 3: An approach to complaints  74Case 15 A woman with chest pain  75Case 16 Clumsiness  78Section 4: Competence 80Case 17 A change in plan  81Case 18 Starving to death 85Case 19 An irregular presentation  88Case 20 Irrational but not incompetent  90Section 5: Restraint 92Case 21 A challenging discharge  93Case 22 Ruling out the organic 96Case 23 Endless wandering 99Case 24 Can you please take these handcuffs off?  101Case 25 Own worst enemy  103Section 6: Miscellaneous  105Case 26 All eggs in one basket  106Case 27 A major mix-up  108Case 28 Under the radar  110Case 29 A cantankerous recluse  113Case 30 Keep an open mind  115Case 31 Healthcare acquired infection?  117Case 32 Backing the wrong horse  120Case 33 A surprising turn of events  122Case 34 Funny turn  125Part 3 Investigating and dealing with errors1 Introduction  1272 How hospitals try to prevent adverse errors and their recurrence  1273 The role of hospital staff  1324 The role of external agencies  1345 Hospital investigations  1376 Legal advice – where to get it and who pays  1417 External investigation of errors and incidents  1438 The role of the doctor  1609 Presenting oral evidence  16210 Emotional repercussions  16411 Conclusion  164References  164Index  167

“My experience as an expert witness in clinical negligence cases, MPTS Panel chairman, medical adviser to a Public Inquiry and as a sometimes commissioned independent reporter on adverse incidents tells me that these are excellent books, valuable for all clinicians, not just those in high-risk specialties; and all NHS managers involved in maintaining or improving the quality of care. The case vignettes, alone, are useful source material for teaching medical trainees on what can go wrong and how to deal with it when it does.” (Harvey Marcovitch, Clinical Risk journal)