Avoidable factors contributing to the death of head injury patients in general hospitals in Mersey Region

Lancet. 1981 Aug 29;2(8244):459-61. doi: 10.1016/s0140-6736(81)90786-8.


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

  • Adolescent
  • Adult
  • Aged
  • Brain Diseases / prevention & control
  • Craniocerebral Trauma / complications
  • Craniocerebral Trauma / mortality*
  • Diagnostic Errors
  • England
  • Female
  • Hematoma / prevention & control
  • Hospitals, General
  • Humans
  • Male
  • Middle Aged
  • Outcome and Process Assessment, Health Care*
  • Surgical Procedures, Operative / standards