- Management of the airway, breathing, circulation, monitoring and oxygen therapy were generally rated highly. However, even in these categories a high proportion of cases (11, 16, 14, 13 and 14% respectively) were rated at the very poor end of the spectrum.
- The most worrying domains were ability to seek advice, appreciation of clinical urgency and supervision; 30%, 21% and 28% of cases respectively were rated at the very poor end of the spectrum.
- ICU admission was thought to be avoidable in 21% of cases.
- Care was classified as less than good practice in 47% of cases.
- In 41 cases where care was classified as less than good practice the deficiencies were considered to be of such significance that they might have contributed to death. This represents 33% of cases classified as less than good care and 11% of all cases reviewed that had sufficient data.