Table 1.

Case 1.

Original narrative	A man in his early 70s with known dementia who required considerable help from family and who frequently wandered, was found in a confused state on a bus. Taken by ambulance to hospital. In A&E observations, urinalysis and blood tests showed no abnormality. The patient was admitted to a medical ward and because he was restless, aggressive and confused on the ward he was sedated. Assessments commenced to determine whether he would be able to return to his home situation. Two weeks later his condition deteriorated suddenly when he developed coughing, tachycardia and reduced oxygen saturations. The working diagnosis was aspiration pneumonia and intravenous fluids and antibiotics were started along with physiotherapy. The patient was transferred to the High Dependency Unit for external respiratory support. Respiratory team review recommended a CTPA which he had next day. It showed bilateral pulmonary embolism and left lower lobe consolidation. No evidence was found that the patient had been given venous thromboembolism prophylaxis up to this point. Anticoagulants were added to his regime. Once stabilised he was transferred to a care of the elderly ward. He deteriorated again three days later and it was decided that as the current ward was unable to provide ‘full care’ active treatment was stopped and the end of life pathway commenced.
Problem in care	Inappropriate admission		Sedation used to control patients behaviour		Failure to provide thromboprophylaxis		Discharge delayed by social factors			Pulmonary embolus misdiagnosed as aspiration	Move to end of life care predicated on ward’s ability to cope with the necessary intensity of treatment
Problem category	Other		Drugs and fluids		Drugs and fluids		Other			Diagnosis	Other
Contributory factors	Availability of alternatives	Effectiveness of communication across health and social care	Risk awareness	Admission to an acute medical ward	Risk awareness	Adherence to protocols	Availability of alternatives			Use of all available information during the diagnostic process	Staff skill mix		Nursing work load
Contributory factor: subcategory	Organisation: structure	Communication: partnership working	Education and training: knowledge	Environment: staffing	Education and training: knowledge	Task: guidelines, policies and proce dures	Organisation: structure	Work environment system design	Communication: partnership working	Staff: cognitive expectation/confirmation bias	Education and training: knowledge	Environment: skill mix and workload	Organisation: safety priorities