When does patient safety end? Our research paper this month suggests that death may not quite be the final cure for life’s ills that Socrates imagined, and finds that lessons from patient safety work need to be applied to mortuary care. Previous reports of people being treated without due dignity and respect after death, as with the scandal of removal and retention of children’s organs at Liverpool’s Alder Hey Hospital, were met with public dismay and outrage.
Liam Donaldson and colleagues analysed a national database over a ten-year period to evaluate the frequency of serious incidents after death.1 They found 132 incidents relating to the storage, management or disposal of deceased patient remains. Fifty-four incidents were classified as storage problems, such as disfigurement or loss of a body part. Forty-three were issues with management, including errors of postmortem examination and postmortems on the wrong side of the body. A further 31 were errors in disposal of bodies, for example, nine were buried or cremated by the wrong family.
While the number of incidents may seem small in relation to the total number of deaths over the study period, the distress that even one incident will cause families and carers is obvious. It is hard to imagine how you might reconcile a family who buried or cremated the wrong body. These findings are a warning to people responsible for mortuary services, say the authors, of the risks of devastating incidents inherent in their care of the deceased. One helpful solution is to adopt system improvement efforts that are well established in patient safety.
Indeed, system improvements are discussed widely in this issue. Harris et al.2 argue for a systematic approach to innovation. Why wait for a light bulb moment when you can devise an innovation strategy, seek support from innovation curators and form international health partnerships to drive innovation? Amy Price and Azeem Majeed3 highlight issues with the NHS Standard Contract that need addressing to improve how secondary care and general practice work together. Muir Gray and colleagues4 address how clinicians must evolve to meet the needs of personalised healthcare. John Scadding closes February with a fascinating insight into his father’s work on clinical trials, whose blend of scepticism and pragmatism is something Socrates might have approved of.5
References
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