1. The Clinicians’ View We think about patients, not populations Reviewing from a population view is about what happened Reviewing from a patient view is about what should have happened Hindsight bias Poor care bias – even if it made no difference

2. Most cases are fairly easy to score and in South Tees most are a Hogan grade 1 or 2

3. Three quick cases based on real cases in South Tees

4. An Easy 1

5. Aet 97 Care Home Resident Mild CFF due to IHD PPM

6. Right sided weakness Partial Anterior Circulation Stroke Probably during night - found 0730 CT at 0900 Thrombolysis at 0944 - alteplase - direct consultant supervision On stroke ward by about 1030 Next day alert, sitting out, but aphasic

7. Good all round care Some notes unclear or difficult to read SALT done early Good rehab MDT plans by day 14 for placement

8. Around day 16 seems to have developed aspiration pneumonia Appropriate re-review of swallow Appropriate antibiotics and physio ABG & DNAR Drowsy "Unlikely to survive" But re-site cannula and vancomycin

9. Next day antibiotics changed on med micro's suggestion And truly a good bit of intrusive care Two more days before "ensure comfortable" But still physio Next day EOLCP But only for hours

10. I am not wholly proud of this care, but it is a 1 We plugged on too long with unpleasant treatment, neglect of palliation when we knew how guarded her outlook was But it is still a 1

11. A straight 6

12. Aet 71 Known AAA under surveillance IHD PVD

13. GP referral Known AAA - 5.1 cm Midline pain spreading through to back A&E ? Leaking AAA

14. A&E noted AAA CT aorta within 30 minutes of arrival. Not leaking but now 5.9cm ? Renal colic, ? Diverticulitis Admit surgeons Discuss with vascular Imaging shows no stone and no clear diverticulitis

15. Day 3 "pain over AAA ++" Refer vascular Seen later on, less tender, but pain is postural and radiates to back MDT Friday

16. Several comprehensive reviews All by FY1 in the night No clear diagnosis made All presumptive diagnoses trivial with no supporting evidence

17. Continued to have low grade reviews, pain but no progress Day 7 0145 - it burst In point of fact we didn't do that well with trying to fix it then, but as the presentation was PEA, Hb 5 the disorganised response was probably unimportant.

18. There were odd features in the presentation But he wasn’t re-imaged and he doesn’t seem to have any high level reviews that actively questioned the putative trivial diagnoses Our urgent AAA results mean his risk of death with surgery was very low

19. A 6 or a 1?

20. A big chap Aet 76 # NOF AF – poorly controlled

21. Rate control with metoprolol Operation went well Back to ward looking OK

22. AF speeds up and BP falls Nothing else obviously wrong Med Reg gives advice on the ‘phone More metoprolol Immediate terminal decline Bloods come back too late - Hb 6

23. The bleeding was not obvious AF speeding up is common in these circumstances Catastrophic bleeding is rare So in the original team’s shoes…