Blackpool’s hospital trust could have learned from 20 patient deaths, an audit carried out last year showed.
The figure was revealed as bosses said they were considering hiring a medical examiner to review all deaths there – and admitted the number was ‘likely to be closer to 40’.
The senior doctor, who would report directly to the town’s coroner, would be tasked with asking families and carers if they had any concerns about their loved one’s care, and to investigate any alleged failings.
Avoidable deaths were discussed at a recent meeting, held at Blackpool Victoria Hospital, after the Care Quality Commission (CQC) said in December that the NHS ‘is missing opportunities to learn’ from them, and called for leaders to develop new national guidelines.
Medical director Prof Mark O’Donnell said learning from deaths should focus on all aspects of healthcare provided and ‘not just on hospital treatment’, documents said.
“Professor O’Donnell advised that there was currently a mechanism for recording deaths,” they added. “However, the guidance was about formalising the process and that this was likely to impact on staff time.
“It was noted that an audit undertaken the previous year indicated that the trust could have learned from 20 patients deaths. However, this was more likely to be closer to 40 deaths and was likely to develop going forwards.”
A number of investigations into patient deaths have been carried out at the Vic in recent years, with the trust making changes to prevent repeats.
Patricia Fowler, 75, died after she was not seen by doctors for three days – because they didn’t know she was there.
And a ‘gross failure’ played a part in Barry Thompson’s death from natural causes, after nurses failed to get the diabetic 70-year-old insulin.
A trust spokesman said: “There trust has always had a focus on learning any lessons it can from all incidents as part of its drive to make improvements to patient safety.”