Summary
The reference event in this HSIB investigation is the case of a 58-year-old woman who deteriorated and died within 24-hours of presenting at hospital, two weeks after having surgery.
The national investigation reviewed relevant research and safety literature relating to recognition and response to deteriorating patients, engaged with national subject matter advisors and consulted with professional bodies.
HSIB report: Recognising and responding to critically unwell patients (May 2019)
https://www.hsib.org.uk/investigations-cases/recognising-and-responding-critically-unwell-patients/
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