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
Preface
Abbreviations
Introduction
Part 1
Errors and their causes
A few words about error
Learning from system failures-the vincristine example
Evidence from the NHSLA Database
The patient consultation
Failure to identify a sick patient
Inability to competently perform practical procedures
Failure to check test results or act on abnormal findings
Prescribing errors
Sources of error in the case of vulnerable adults
References and further reading
Medico-legal aspects
Error in a legal context
Negligence
Clinical negligence
Issues around consent
An attorney refusing treatment
A patient without capacity refusing treatment
Emergency treatment
Deprivation of liberty safeguards
Part 2 Clinical cases
Introduction
Civil liability, Negligence and Compensation
Case 1 A Shaky Excuse
Case 2 Making Matters Worse
Case 3 Chase the Bloods
Case 4 Falling Asleep En-Route
Case 5 Bad Luck or Bad Judgment
Case 6 An Opportunity Missed
Case 7 Better Late than Never
Case 8 Man Down
Case 9 Cry Wolf
Case 10 Not a Leg to Stand On
Unexpected death – the Coronial System and Clinical Risk Management
Case 11 Doubly Bad Outcome
Case 12 Difficulty with Diarrhoea
Case 13 A Flu-like Illness
Case 14 Falling Standards
An Approach to Complaints
Case 15 A Woman with Chest Pain
Case 16 Clumsiness
Competence
Case 17 A Change in Plan
Case 18 Starving to Death
Case 19 An Irregular Presentation
Case 20 Irrational but not Incompetent
Restraint
Case 21 A Challenging Discharge
Case 22 Ruling Out the Organic
Case 23 Endless Wandering
Case 24 Can you Please Take these Handcuffs Off?
Case 25 Own Worst Enemy
Miscellaneous
Case 26 All Eggs in One Basket
Case 27 A Major Mix-up
Case 28 Under the Radar
Case 29 A Cantankerous Recluse
Case 30 Keep an Open Mind
Case 31 Healthcare Acquired Infection?
Case 32 Backing the Wrong Horse
Case 33 A Surprising Turn of Events
Case 34 Funny Turn
Part 3 Investigating and dealing with errors
Introduction
How hospitals try to prevent errors and their recurrence
The role of hospital staff
The role of external agencies
Hospital investigations
Legal advice – where to get it and who pays
External investigation of errors and incidents
The role of the doctor
Presenting oral evidence
Emotional repercussions
Conclusion
Further reading
Index
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