Table 2 Reported quality of medical interventions

Minimal

Patient condition deteriorating. Doctors intervention minimal. Doctors not answering bleep.

71

Delayed

Admitted with acute septic arthritis of failed knee replacement and collapse at home while waiting revision. Subsequently died

24

Mistreated

Patient deteriorated over two days. Patient received possible sub-optimal care; observed not frequent enough, deterioration score not calculated correctly, lack of documentation and medical review, escalation not timely.

22

Inappropriate

A cardiac arrest call put out at 18.17, ALS procedure followed. Patient died. Examination of the medical notes and vital signs prior to this event reveal clear premonitory signs. Patient reviewed by SHO on 7/5/05 for hypotension. Gelofusin administered. It appears there is no further medical review until 9/5/05, time not stated. On the 8th at 22.00 the vital signs chart shows atrial fibrillation, rate 280. Vital signs show tachypnoea and persistent hypotension (Note seagull sign). Between 22.00 and 07.00 vital signs only done once, no time stated .No documented medical review.

9