Day 918

Biggest cause of avoidable deaths in children and young people – Suicide and self-inflicted injuries

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The Office of National Statistics published a report in 2015 saying that the  single cause with the highest number of avoidable deaths in children and young people was suicide and self-inflicted injuries (14% or 206 deaths of all avoidable deaths in this age group).

Of the top five causes of avoidable deaths among children and young people, suicide and self- inflicted injuries was the only cause to see an increase since 2014 by 13% or 24 deaths.

Avoidable mortality accounted for 3 out of 10 deaths of children and young people (aged 0 to 19 years), nearly the same as in 2014. Males accounted for almost two-thirds (63%) of avoidable deaths in children and young people.

The other top causes each saw a decline since 2014, with accidental injuries, which was the leading cause in 2014, experiencing the largest decline of 8% or 15 deaths.

 

Key Points for London

  • The rate of avoidable mortality in London has increased to 210.4 deaths per 100,000 population from 204.6 in 2014. This is significantly lower than for England (222.9).
  • The South East, East of England and South West Regions have lower rates of avoidable mortality than London. The highest rate is in the North East (266.4).
  • As in all other regions, avoidable mortality rates in London are higher for males (274.0 deaths per 100,000 population) than for females (152.9). Rates have increased for males (from 259.9 in 2014) and slightly reduced for females (154.3 in 2014).
  • Ref: https://www.gov.uk/government/statistics/avoidable-mortality-in-england-and-wales-2015

 

Day 856

Every investigation into an avoidable death is a learning opportunity for Trusts, clinicians, families, wards, patients, management, boards and the community. The lessons learnt can be passed on to other organisations and future generations. But unfortunately, often investigations are done in order to not find any deficiencies. They are defensive in nature rather than exploratory. They are reductive and analytical (Root cause Analysis) rather than holistic and empathic. Both approaches bring value to an investigation but often the greater good that can come out of them is overlooked.

200 avoidable deaths take place within the NHS every week. Each of them holds valuable lessons for the future but they are buried. Hence the same mistakes happen over and over again, costing more and more lives. In some organisations serious near-misses are recorded as ‘no-harm caused’.

We need collective intelligence, not individual genius. We need responsibility and accountability, personal and professional, shared and individual.

In 2015, a report was leaked to the BBC from Southern Trust that looks after 45,000 people. They had 1454 unexpected deaths over a 4 year period, 2011-2015. Of those, just 195 (13%) were treated by the trust as serious incidents requiring investigation. Deaths of adults with mental health issues were most likely to be investigated (30%). For those with learning disability the figure was 1%, and among over-65s with mental health problems it was just 0.3%.

“To err is human, to cover-up is unforgivable, to fail to learn is inexcusable.”
– Sir Liam Donaldson.

Ref: NHS Failure to probe deaths: Shocking: http://www.bbc.co.uk/news/health-35061716