Confidential paediatric inquiry into neonatal deaths in Wessex, 1981 and 1982.

From 1 January 1981 to 31 December 1982, 66 256 births and 386 neonatal deaths were recorded in the Wessex Regional Health Authority, giving a neonatal mortality of 5.8/1000 live births. An experienced consultant paediatrician undertook a confidential inquiry into each death shortly after it had been reported. One hundred and forty four deaths (37%) were found to be due to lethal or severe malformations, an incidence of 2.2/1000 births. Of the 242 normally formed infants, 111 (46%) died within 24 hours of birth. Seventy seven (32%) weighed over 2500 g at birth. Factors operating before delivery accounted for 104 (43%) of the deaths of normally formed infants. The commonest factors were short gestation and low birth weight, and intrauterine hypoxia and birth injury. Factors after delivery accounted for 81 deaths (33%), the commonest being infections and sudden infant deaths. In the remaining 57 deaths (24%) it seemed that a combination of factors before and after birth had led to the death. Factors before birth thus played a part in two thirds of all deaths. Possible adverse factors in medical care were sought in 154 potentially viable babies and were identified in 38--that is, 10% of all neonatal deaths. Better provision and training of district staff in immediate care at birth would achieve more in lowering neonatal mortality in Wessex than the setting up of a regional unit specializing in advanced neonatal intensive care. Moreover, the greatest scope for improving the outcome of childbirth in Wessex would be offered if there were further advances in obstetric rather than neonatal care.     

Local confidential inquiry into avoidable factors in deaths from stroke and hypertensive disease.

OBJECTIVE--To audit avoidable deaths from stroke and hypertensive disease. DESIGN--Details of care before death were obtained from general practitioners and other doctors, anonymised, and assessed by two experts against agreed minimum standards of good practice for detecting and managing hypertension. SETTING--Health authority with population of 250,000. SUBJECTS--All patients under 75 years who died of stroke, hypertensive disease, or hypertension related causes during November 1990 to October 1991. MAIN OUTCOME MEASURES--Presence of important avoidable factors and departures from minimum standards of good practice. RESULTS--Adequate information was obtained for 88% (123/139) of eligible cases. Agreement between the assessors was mostly satisfactory. 29% (36/123, 95% confidence interval 21% to 37%) of all cases and 44% (36/81, 34% to 55%) of those with definite hypertension had avoidable factors that may have contributed to death. These were most commonly failures of follow up and continuing smoking. Assessment against standards of minimum good practice showed that care was inadequate but not necessarily deemed to have contributed to death, in a large proportion of patients with definite hypertension. Common shortcomings were inadequate follow up, clinical investigation, and recording of smoking and other relevant risk behaviours. CONCLUSIONS--This method of audit can identify shortcomings in care of patients dying of hypertension related disease.     

An investigation into general practitioners associated with high patient mortality flagged up through the Shipman inquiry: retrospective analysis of routine data

Objective To identify a credible explanation for the excessively high mortality associated with general practitioners who were flagged up by the Shipman inquiry.Design Retrospective analysis of routine data.Setting Primary care.Participants Two general practitioners in the West Midlands who were associated with an unacceptably high mortality of patients during 1993-2000.Main outcome measures Observed and expected number of deaths and deaths in nursing homes.Results Preliminary discussions with the general practitioners highlighted deaths in nursing homes as a possible explanatory factor. No relation was found between the expected number of deaths and deaths in nursing homes in each year during 1993-2000 for either general practitioner. In contrast, the magnitude and shape of the curves of a cumulative sum plot for excess number of deaths (observed minus expected) in each year were closely mirrored by the magnitude and shape of the curves of the number of patients dying in nursing homes; and this was reflected in the high correlations (R² = 0.87 and 0.89) between excess mortality and the number of deaths in nursing homes in each year for the general practitioners. These findings were supported by administrative data.Conclusions The excessively high mortality associated with two general practitioners was credibly explained by a nursing home effect. General practitioners associated with high patient mortality, albeit after sophisticated statistical analysis, should not be labelled as having poor performance but instead should be considered as a signal meriting scientific investigation.     

Pesticides linked to bee deaths

For the first time, a chemicals company has paid compensation to beekeepers for loss of colonies. Michael Gross reports.