title: Avoidable factors contributing to the death of head injury patients in general hospitals in Mersey Region.
abstract: In 1975 and 1976 190 head injury patients died after admission to 19 general hospitals in Mersey Region or after transfer to the regional department of neurosciences. Their hospital case-notes were examined. Avoidable factors definitely contributing to death were identified in 58 (30%), and those possibly contributing to death in another 45 (24%). Of the avoidable factors 38% occurred in patients who "talked and died" and 77% in patients with intracranial haematomas. The most common avoidable factors were failure to recognise the development of a haematoma, respiratory difficulty leading to hypoxia, hypotension, and convulsions. The following recommendations are made: hospital case-notes of all head injury deaths should be assessed by a panel of senior consultants; all patients unconscious for 4 h in primary surgical wards in general hospitals should be transferred to the regional department of neurosciences; and fewer patients with minor head injuries should be admitted for observation.
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D001927:Brain Diseases / Q000517:prevention & control; D006259:Craniocerebral Trauma / Q000150:complications / Q000401:mortality*; D003951:Diagnostic Errors; D004739:England; D005260:Female; D006406:Hematoma / Q000517:prevention & control; D006769:Hospitals, General; D006801:Humans; D008297:Male; D008875:Middle Aged; D010043:Outcome and Process Assessment, Health Care; D013514:Surgical Procedures, Operative / Q000592:standards