Reaction to Hans’ Root Cause Analysis

As Hans‘ parents we are not satisfied having read the Regional Pre-Hospital’s root cause analysis over the course of actions leading  to our son’s death on 1/1/2017.

At a meeting with the emergency services in March, we were told that in a root cause analysis you ask “why” until it stops making sense, and that Hans’ root cause analysis would be conducted by independent highly competent people.

The analysis arrives at a number of causes and action plans, but the causes are too superficial and the action plans too weak.

In the analysis is stated:
Lack of specific training in very rare but very serious time-critical acute illnesses increases the risk of missing danger signals.
 There is however no specification as to who will receive this training. All SFVs? The doctors employed? Nurses? The associated action (using the term loosely) is: “It’s recommended that the emergency service focus on ongoing information about rare but acute dangerous diseases, e.g. by using check-lists and seasonal varied postings and in time e-learning” To call this recommendation a weak “action” is almost giving it more credit than it deserves.

The Patient Compensation Board has found it probable beyond reasonable doubt that Hans’ died because of substandard visitation and the Danish Patient Safety Authority has found the Doctor responsible to demonstrate an unacceptable low clinical standard and sanctioned her to be under supervision for a year.

The lack of training (or rather clinical competencies) by the doctors on 1813 is according to the patient compensation board a probable cause leading to Hans’ death, but it is not the root cause. For that you must find the answer to the question: How can there be clinical incompetent doctors as backup for the visitator? Who hires them and why?

The doctors associated with 1813 have a very varied background. Psychiatrists, plastic surgeons, ophthalmologists, gynaecologists, etc.  There are also doctors with no specialty and – even worse – with no significant prior experience with emergency medicine.  Due to a conflict between RH and PLO, there are no (or very few) from the most relevant specialist area: General Medicine. In the original emergency medical care system (“Vagtlæge”), replaced by 1813, the doctors were required to be specialists in General Medicine and to have several years of experience in the field. One of the mistakes committed during Hans‘s course was that the doctor did not diagnose a meningococcal infection. She could/should have done that solely on the basis of the first 20 seconds of the conversation between Hans and 1813, and should there have been the slightest doubt, that doubt would be eliminated on the basis of the photos Hans sends in showing his petechiae and purpura. This is an opinion we share with the Danish Patient Safety Authority.

The purpose of a root cause analysis is to find the root cause behind an incident; thus the name. The motive for finding the root cause is to identify possible institutional or fundamental faults so these can be corrected and future occurences of similar incidents prevented.

This is where Hans’ root cause analysis fails completely. It should, on the basis of his and probably others cases ask:

Is patient safety in the Region’s Emergency Services  impaired due to lack of relevant specialties and experience among staff doctors?
The burden of proof that this is NOT the case must lie with the Emergency Services themselves.

It is very worrying that in a root cause analysis, where both the initial visitating person and the responsible doctor lacked both relevant training and experience and are sanctioned for not meeting required professional standards, it is not seen as relevant to draw into question the (lack of) experience and training as a possible root cause. It hard to believe that there should be clinical objective reasons behind not looking at this and we suspect that the potential political consequence of drawing the organisation and basis of 1813 into question has spooked the involved professionals. This even more so, as it comes to light, that the chairman of the analysis team was NOT the independent outside expert we were promised, but rather the CEO of the emergency services. I.e. this person decides whether to question management decisions regarding required skills and experience that he had originally made himself. Very disappointing, but not surprising, that it never becomes a topic.

Here I also want to note, that the argument “Mistakes were also made under the old scheme” as a complete strawman. Yes, mistakes will always be made when humans are involved, but it should be obvious that they are more likely to be made by a doctor with no specialty and no relevant or current emergency  medical experience than by a doctor specialising in general medicin and current year long relevant experience.

Lacking a proper analytical approach to these questions we can only speculate and will also ask:
How many lives will the conflict between RH and PLO cost before they put their squabbles over power and money aside and give the citizens the best possible Emergency Services?

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