Table 3 Frequency of core themes occurring within the structured judgement reviews, divided according to the overall judgement of avoidability. Patients may have been exposed to more than one theme
Theme | Avoidability score | ||
|---|---|---|---|
1–3 (> 50% avoidable) | 4–5 (< 50% avoidable) | 6 (not avoidable) | |
TOTAL | 38 | 151 | 461 |
Below optimal care | 10 | 40 | 126 |
Delay in testing | 8 | 32 | 99 |
Delay in Accessing care | 11 | 29 | 20 |
Capacity Issues (community services) | 2 | 3 | 3 |
Exposure to COVID-19 | 1 | 19 | 129 |
Delay in Response | 1 | 15 | 16 |
COVID-19 on MCCD without diagnosis | 1 | 2 | 47 |
Communication Barrier | 1 | 2 | |
Advised to Self-Isolate | 1 | 1 | 2 |
Potential Misdiagnosis | 1 | 5 | |
Patient refusal to go to ED | 1 | ||
Transfer to IMC no testing | 5 | 3 | |
Sudden Death | 1 | 8 | |
Remote consultation | 1 | ||
Self-Discharge | 1 | ||
Delay in COVID-19 Swab Results | 1 | ||
Family Insistence on transfer to ED | 1 | ||
Hospital Acquired Infection | 1 | ||