Table 3 Opportunities for improvement in the preventable group of deaths as identified by peer-review

Resuscitation related:

Delayed control of pelvic abdominal hemorrhage

51

2.5

Delayed control of intrathoracic hemorrhage

25

1.2

Delayed resuscitation

108

5.2

Inadequate resuscitation

152

7.4

Lack of blood

11

0.5

Protocol lack or lack of adherence:

Intensive monitoring required

109

5.3

Unavailability of ventilator

39

0.1

Unstable patient sent to CT

9

0.8

Inappropriate ventilatory management

1

1.9

Delay in cervical spine

9

0.4

Left to die

49

2.4

Prehospital delay

212

10.3

Unknown cause

4

0.2

Lack of investigations

11

0.5

Lack of protocols

24

1.2

Lack of adherence to protocols

4

0.2

Head Injury and Airway related:

Airway

293

14.3

Traumatic Brain injury

307

14.9

No CT uninvestigated

56

2.7

Untreated head injury

64

3.1

Untreated head injury-no surgery done

109

5.3

Surgery related:

Inappropriate surgery done

5

0.2

Unduly long surgery done

61

3.0

Unstable patient operated on

5

0.2

Negative explorations

1

0.1

Injury prevention:

Burns prevention

117

5.7

Long stay complications:

DIC

1

0.1

Sepsis

39

1.9

Pneumonia

16

0.8

Old age related complications

19

0.9

Ventilator related complications

104

5.1

Miscellaneous issues:

Could not be determined

26

1.2

Misclassified

5

0.2