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The article is short so doesn't really delve into what happens after those deaths - specifically investigation into cause or the legal ramifications.

I was hoping to get that info because the first thing that popped into my mind was that people are/were apparently dying due to unnecessary reasons if a simple checklist prevents 37% of surgical deaths. If that's the case, the only way I could imagine classifying those deaths would be "gross negligence" and therefore not subject to the protections of the legal agreements you sign before surgery.

I can't talk about Scotland because they have a devolved system and I have no idea how it works up there.

I can talk a little bit about England.

There are two main ALBs (arms length bodies) that will be involved: NHS Resoulation (the organisation that handles legal cases) and NHS Improvement (the organisation that handles QI work). NHS England and NHS Improvement are merging and I don't know what the new name will be. NHS Resolution used to be called NHS Litigation Authority.



The information that NHSi has about "Just Culture" is here: https://improvement.nhs.uk/resources/just-culture-guide/

If you have a look at this flow-chart you can see that they're trying to find out if an incident that caused harm was deliberate, grossly negligent, caused by wider system failings, etc. https://improvement.nhs.uk/documents/2490/NHS_0690_IC_A5_web...

If you have a look at NHS Resolution's page about learning from harm you can see that they're keen for healthcare professionals to 1) Say sorry, 2) explain in full what went wrong 3) Explain how that's going to be prevented in future. https://resolution.nhs.uk/services/safety-and-learning/

This expands upon a legal duty of HCPs and NHS Trusts in England: the Duty of Candour.

Here's the advice for doctors: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for...

And nurses: https://www.nmc.org.uk/standards/guidance/the-professional-d...

And other registered healthcare professionals: https://www.hcpc-uk.org/assets/documents/10003f72enc07-dutyo...

And organisations: https://www.cqc.org.uk/guidance-providers/regulations-enforc...

If a patient does decide to sue I think they can only recoup their actual losses. I think we don't have punitive damages in England.

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