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For emergency responders, some incidents don’t end when the scene is cleared. Long after a patient has been handed over, or after every effort has been made to help someone who didn’t survive, clinicians can still be left with the same difficult questions about what exactly happened, whether the right decisions were made in those critical minutes, and whether anything could have changed the outcome.
At Essex & Herts Air Ambulance, those questions are being tackled through a more comprehensive approach to case review that aims to improve patient care, strengthen learning and offer reassurance to crews who are often dealing with the most traumatic incidents imaginable.
The charity has introduced a model of reviewing every patient death attended by its critical care teams, rather than limiting detailed scrutiny to cases where there is already concern that something went wrong. The process, known as Clinical Pathological Correlation (CPC), brings together frontline clinicians with forensic pathology expertise so that what happened at scene can be compared with post-mortem findings and the wider clinical picture. According to Dr Gareth Grier, Associate Medical Director (Centre for Excellence) at Essex & Herts Air Ambulance, the approach is helping the organisation move beyond assumption and learn from every case it can.
Grier, who is also an emergency medicine consultant and has worked in pre-hospital care for many years, said the foundations of the model came from a frustration shared across emergency medicine. Teams often commit huge resources, skill and emotional energy to critically unwell patients, only to receive little or no information afterwards about the final diagnosis or precise cause of death.
“We send significant resources, often including a helicopter, and there are intensive, strenuous efforts invested at the scene to try and resuscitate someone or get them treatment as quickly as possible. Then historically you come to review the case and you don’t really get to the bottom of what it was that resulted in the death of the patient, and therefore could we have done differently to help, or to help the patients of the future.”
Dr Gareth Grier, Associate Medical Director (Centre for Excellence).
That challenge can be particularly acute in pre-hospital care, where crews may never see the scans, hospital treatment notes or post-mortem findings that would help explain what they were dealing with in real time. Where a death is referred to the coroner, access to that information has traditionally been limited, even though it may contain the most valuable learning for the clinicians involved.
“For many years we would undertake these case reviews, but you would never get the post-mortem information,” said Grier. “At best, it was the best guess of the clinicians in the room without access to scans or anything you would have in hospital. You’re basing assumptions on your clinical judgement at the time, and we never even knew how accurate that was.”
Essex & Herts Air Ambulance’s response has been to normalise case review rather than reserve it for moments of failure. Every death attended by the charity can now become an opportunity to understand injuries, test clinical judgement, review interventions and identify themes that may shape future practice. Grier believes that distinction matters because traditional review models can place staff immediately on the defensive, whereas universal review encourages openness.
“In hospital medicine and more widely in the NHS, meetings often happen because something is believed to have gone wrong. What we’re trying to do here is review every death regardless of whether there was assumed to be a problem or not. It creates a safer psychological space for people to share their experience, because they’re not on the back foot when they come to the meeting.”
The CPC model relies heavily on collaboration with forensic pathologists, including Dr Ben Swift, whose expertise helps clinicians interpret complex findings and correlate them with what crews saw at scene. That can be especially important in trauma, where the obvious injury is not always the injury that proved fatal.
“You’re bringing together two groups of experts who see things through very different lenses but around similar cases,” said Grier. “What they bring overwhelmingly is the detailed information found at post-mortem that we would not normally have access to, but also the ability to help interpret those findings.”
He gave the example of head injury, where the broad label can conceal several very different fatal mechanisms, from bleeding in one area of the brain to skull fractures or the effects of oxygen deprivation immediately after impact. Understanding which process was dominant can shape both learning and innovation.
“If you think all your patients are dying of punctured lungs, when actually they’re dying of bleeding, then you’ve got a different strategy for those two very separate entities,” he said. “But you can’t know that until you’ve put the information together.”
In one historic motorcycle collision review, teams initially believed catastrophic bleeding had been the principal reason the patient died. The later correlation process suggested that although there had been some bleeding, the decisive factor was likely a blocked airway and severe lack of oxygen in the minutes before emergency services arrived. For Grier, that sort of finding demonstrates why accurate retrospective diagnosis matters.
“If you assume that bleeding was the number one cause, you might decide the answer is to carry more blood or develop more novel interventions for bleeding. But actually the answer to that question should come from what happens in the ambulance control room when someone is unconscious. How do you coach bystanders to help before the emergency services even get there?”
That lesson has informed his enthusiasm for technology that allows control room staff to support callers visually through video links, helping guide CPR or airway management before crews arrive. Grier described those early moments before responders reach scene as a “therapeutic vacuum”, particularly in serious head injury, where a patient who cannot maintain their airway can deteriorate rapidly.
Alongside operational learning, Grier said the process has an important human value for clinicians. Many responders carry doubt after difficult jobs, particularly when outcomes are poor. Access to definitive findings can relieve unnecessary guilt and help teams process traumatic events more realistically.
“There’s nothing worse than wondering whether you should have done something, could have done something, could have got there quicker,” he said. “I’ve met so many clinicians over the years who have been extremely troubled by a case because in their own mind they developed a concept that was actually never the concept. Now that we get access to the information, we’re often able to say sadly this patient was never going to survive those injuries.”
The benefits can extend to families as well. Through its patient and family liaison work, the charity may help relatives understand complex medical findings, particularly where post-mortem reports arrive full of technical terminology and before an inquest has taken place.
Within the organisation, he said staff have responded positively to the idea that every case is reviewed, partly because case discussion has long been embedded in the charity’s culture. Rather than fearing scrutiny, clinicians frequently bring cases forward themselves because they want to know what happened and what others can learn from it.
While Grier acknowledges that air ambulance charities have some structural advantages, including the ability to bring teams together for dedicated learning time, he believes the wider principle is relevant across emergency medicine and beyond. Whether in ambulance services, emergency departments, fire and rescue or policing, organisations dealing with high-stakes incidents can benefit when review is routine, evidence-led and focused on improvement rather than blame.
“Our recommendation in the paper is that this becomes a standard to expect in the air ambulance community. You can’t really get to the bottom of a case where someone has passed away unless you have that information, because otherwise you can go down a rabbit hole of the wrong conclusion and the wrong assumption.”
Ultimately, Grier said success is not measured simply through governance processes or published papers, but through the confidence that comes from truly understanding what happened in the most difficult cases.
For clinicians, that may mean reassurance that nothing more could have been done. For families, it can mean clearer answers at an incredibly painful time. And for the service, it means every case has the chance to improve the next one. ‘’We’re determined to help families understand that everything possible was done and that no stone has been left unturned,’’ he said.
Click here to read the full paper.
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