CORRELATION OF ADVERSE EVENT, HARM AND DEATH

• Jurisdiction: Australia

DEATH

Temporal relationship .................................................................................... [33E.1200]

Nature of the linkage between incident and harm; harm and death ............ [33E.1210]

Cause of death and causation ...................................................................... [33E.1220]

Natural cause ................................................................................................ [33E.1230]

Natural cause and deficit in care .................................................................. [33E.1240]

Natural cause, deficit in care and patient harm............................................ [33E.1250]

Patient harm and deficit in care .................................................................... [33E.1260]

Patient harm and no deficit in care............................................................... [33E.1270]

[33E.1200] Temporal relationship

Obtaining a clear understanding of the temporal relationship of the incident, occurrence of harm and subsequent death is a vital first step. Most adverse events or incidents do not lead directly or immediately to death. Adverse incidents often precipitate a cascade of clinical investigations and treatments, and are then modified by ongoing disease processes and a patient's response to therapy. For example, a patient aspirates at induction of an anaesthetic, develops pneumonia, is admitted to intensive care and gets a secondary infection causing renal failure and eventually dies of multi-organ failure some months later. In this situation, it is most unlikely that the autopsy will shed any light on the original adverse event.

This is simplistically described by considering the following:

• whether the relationship of the incident to harm is proximate or distant and
• whether the relationship of the harm to death is proximate or distant?

For an example of where "incident to harm" and "harm to death" are proximate: a patient presents to an emergency department with chest pain, the medical practitioner misses the diagnosis of a dissecting thoracic aneurism and death occurs within hours. For an example of where "incident to harm" and "harm to death" are distant: a patient with a history of migraine presents to an emergency department with an unusual headache, the medical practitioner does not order a CT brain scan and discharges the patient home. Some weeks later, a brain tumour is diagnosed and the patient dies months later from complications of surgery.

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