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Litigation associated with intensive care unit treatment in England: an analysis of NHSLA data 1995–2012

Pascall.BJA;2015;115(4):601-7.doi:10.1093/bja/aev285

Clinical Question

  • In patients who were admitted to the ICU what litigation claims were made and what was their cost?

Design

  • Retrospective observational analysis
  • Data obtained with ‘Freedom of Information’ request (September 2012) to National Health Service Litigation Authority (NHSLA –  manage negligence and other claims made against the NHS in England)
  • Data requested: claims associated with intensive care, clinical description, whether claim open/closed, withdrawn/settled out of or in court; vale of any payments and legal costs
  • Date independently reviewed and classified by 3 parties (Two consultant intensivists working independently, and two 4th year medical students working together). Classification accepted when all 3 parties agreed
  • Costs and damages corrected to 2013 values using annualised retail price indices

Setting

  • All NHS Intensive care units (including paediatric and neonatal ICUs) in England
  • 1995 –  2012

Population

  • Inclusion: Claims notified to the NHSLA that were associated with intensive care
  • Exclusion: Claims judged to have been misclassified, not related to intensive care, claim related to care before or after ICU treatment, inadequate or uninterpretable information
  • 523 claims analysed of whom 210 claims excluded from final analyses

Outcome

  • Primary outcome: No primary outcome specified
  • Claims by year: Number of claims increased from eight claims in 1995-1997 to 68 claims in 2003-2005. 20% of claims made ≥4 years after incident
  • Most common clinical categories of claims:
    • Positioning/nursing standards/skin care (predominately related to pressure sores) 27.5%
    • Infection 25.5% (of whom a quarter relate to the acquisition of MRSA)
    • Respiratory/airway 20.1%
    • Paediatrics 17.8%
    • Vascular access 14.1%
  • Clinical category with highest number of claims relating to patient death:
    • Respiratory/airway 33
    • Missed/delayed diagnosis 22
    • Paediatrics 19
  • Clinical categories with highest number of claims associated with severe or fatal outcome:
    • Positioning/nursing standards/skin care 80
    • Infection 64
    • Respiratory/airway 55
  • Cost of claims
    • 71.7% of 244 closed claims led to cost totalling £20 million (Mean £82,000, median £726,000)
    • Categories in which claims most frequently led to cost:
      • Failure to monitor or identify deterioration 81.8%
      • Delayed/inadequate treatment 81.3%
      • Infection 78.8%
    • Clinical category with highest overall costs:
      • Infection £6.6 million
      • Positioning/skin care/nursing standards £4.5 million
      • Delayed/inadequate treatment £4.3 million
      • Missed/delayed diagnosis £3.9 million
    • Clinical category with highest mean total cost per case:
      • Withdrawn/withheld treatment £429,000
      • Obstetrics £164,000
      • Failure to monitor/identify deterioration £162,000
    • Damages to claimants accounted for 61% of all costs and payments to legal teams accounted for 39%

Authors’ Conclusions

  • Claims following ICU care and common, costly and likely to follow a poor outcome

Strengths

  • Study covered long time period and large number of intensive care units
  • Claims classified by 3 parties with agreement. 4th consultant intensivist to adjudicate in cases of disagreement, all though this was not required
  • Study is on an area of practice that is relevant, yet poorly studied and understood by clinicians

Weaknesses

  • Number of claims excluded due to lack of detail. In those cases that were included, the clinical details were limited as the database used is not intended for clinical analysis. Authors were unable to review clinical notes to ensure accuracy of data presented
  • Retrospective review
  • No method to check if any claims had not been reported to NHSLA
  • Claims that may relate to care in last few years of study may have not been made at time that data was collected

The Bottom Line

  • In 17 years, £20 million has been spent on claims relating to ICU care in NHS hospitals in England. The most common claims related to pressure sores followed by infection, including the acquisition of MRSA. The clinical category with the highest number of claims related to patient death was respiratory/airway followed by missed/delayed diagnosis. Intensive care units should review their practice to ensure that they have guidelines, staffing and environments that minimise the risks identified.  This study highlights the importance of good quality note keeping to enable staff to write statements on events that occurred ≥four years previously.

External Links

Metadata

Summary author: @davidslessor
Summary date: 19th October 2015
Peer-review editor: @avkwong

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