Prosaic as it might sound, the above article is unusually important  – the medical examiner system in England will now examine case notes of many deaths, and case note review is the only real method to assess the technical quality of medical care – so called trigger tools miss most of the important stuff. This systematic review finds that between half and three quarters of stated causes of death are wrong. This is not surprising given that implicit case note review has high measurement error. The gold standard here is an external systematic review, such as the proposed medical examiner system. Such a method still misses many of the real causes and post-mortem is the ultimate standard. The authors provide a lot of guidelines for future investigators proposing case note reviews.
— Richard Lilford, CLAHRC WM Director
- Rampatige R, Mikkelsen L, Hernandez B, Riley I, Lopez AD. Systematic review of statistics on causes of deaths in hospitals: strengthening evidence for policy makers. Bull World Health Organ. 2014;92:807-16.