1. Despite gains in reducing mortality from adverse effects (AEs) in the UK, progress has not been achieved in the reduction of incidence from AEs between 1990 and 2013 2. A direct link between deprivation level & health loss from AEs in England & the English regions is apparent, though vary, between most deprived & least deprived 3. DEPRIVATION LEVEL MATTERS on outcomes from AEs.

1. ADVERSE EFFECTS OF MEDICAL
TREATMENT IN THE UK, 1990-2013:
levels, trends, patterns, and comparisons
Raimundas Lunevicius,
Aintree University Hospital NHS Foundation Trust, Liverpool, England
Juanita A. Haagsma,
Erasmus University Medical Center, The Netherlands
University of Washington, USA
14th Sep 2016, Grand Rounds,
Aintree University Hospital NHS Foundation Trust, Liverpool, England
1

2. Content
• Injury: definition & classification
• Knowledge on incidence & outcomes from AEs
• GBD interactive data visualisation tools
• The aim & two objectives
• Methods
• Results
• Conclusions, interpretations, take-home messages
• 25 minutes
• 47 slides
slides No. 22, 31 and 43 are the essence of this talk
Introduction 2

3. Injury definition: comprehensive & simplified
• Any damage to the human being body resulting from
acute exposure to thermal, mechanical, electrical, or
chemical energy or the absence of such essentials as
heat or oxygen
• Any damage to the human being body resulting from
acute exposure to external cause
Johns Hopkins University, 2008
Introduction 3

4. Classification
• Injuries
• Intentional and Unintentional
• Intentional:
• Suicide or attempt to commit suicide
• Homicide or attempt to commit homicide (man’s assault, Polonium-210, etc.)
• Unintentional injuries:
• Transport events
• Falls
• Poisoning: illicit drugs, alcohol,
• Drowning
• Fire & heat
• Frost
• Animal contact: bites
• Natural disasters: lightning, flood, earthquake, hurricane, tsunami..
• Adverse effects of medical treatment
Introduction 4

5. Unintentional
injuries
http://vizhub.healthdata.org/gbd-
compare/
Death rates in four
countries in individuals
of all ages in 2013, by
gender and unintentional
injury cause
Introduction 5

6. Unintentional
injuries
(falls excluded)
http://vizhub.healthdata.org/gbd-compare/
England, females:
AE = Road injuries
Scotland, females:
AEs > Road injuries
Introduction 6

7. Knowledge on AEs: scanty
• Acute Care Trusts / England
• 10%: experience an AE
• 1/3 of AEs: moderate / severe disability or death
• 8%: case fatality rate
• Patient safety related incident data base
• less than 0.5% of incidents involved death
• No certainty
1. on trends, patterns in incidence & mortality over time
2. re a rank of the UK at the global level
3. about the relationship between deprivation level & health loss/AE
Introduction
Illingworth J, Is the NHS getting safer? 2015
Vincent C, BMJ, 2001
Neale G, JRSM, 2001
7

8. Global Burden of Disease study (GBD)
• Provides a standardised approach to address the problem
• Definition: GBD is a systematic, scientific enterprise to
measure epidemiological levels of and quantify the magnitude
of health loss from diseases, injuries, and risk factors by age,
gender, and geography for specific points in time.
• Interactive data visualisation tools & models / population level
• http://vizhub.healthdata.org/gbd-compare/
• http://vizhub.healthdata.org/gbd-compare/england
• http://vizhub.healthdata.org/epi/
• http://vizhub.healthdata.org/cod/
• http://vizhub.healthdata.org/le/
Introduction 8

9. One aim & two objectives
To show whether the UK itself made progress in reducing
the burden of AEs over the period of 24 years - 1990-2013:
1. to provide levels, trends, patterns and comparisons of
incidence & mortality from AEs
• for the UK,
• four constituent countries of the UK,
• the 9 regions of England
2. to show how levels, trends and patterns generated from
estimates of deaths & DALYs from AEs depend on
socioeconomic deprivation level in England
Introduction 9

10. Data, metrics, time points
• Interactive data visualisation tools
• Epi Visualization http://vizhub.healthdata.org/epi/
• GBD Compare http://vizhub.healthdata.org/gbd-compare/
• GBD Compare – Public Health England http://vizhub.healthdata.org/gbd-compare/england
• Incidence & mortality rates for the UK are age-standardised
• The ratio 1 – M/I is a proxy for survival rate
• Death & DALY rates for individuals of all ages: England
• Years 1990, 1995, 2000, 2005, 2010, and 2013
• Office for National Statistics, National Records of Scotland,
Northern Ireland Statistics and Research Agency
Methods 10

11. Definition: DALY / Disability Adjusted Life Years
• A DALY is the summary measure of years of life lost (YLL)
due to premature mortality (i.e. total loss of health) and
years lived with disability (YLD) due to partial loss of
health
DALY = YLL + YLD
Life expectancy at birth – calculating DALY
Methods 11

12. Codes of AEs (for medicine & surgery combined)
• ICD-9 codes
• E870.0–E870.4, E870.7–E870.9, E871.0, E871.1, E871.4–E871.8, E872.1–E872.5, E872.9, E873.0–
E873.3, E873.6, E873.8, E873.9, E874.0, E874.1, E874.4, E874.5, E874.8, E874.9, E875.0, E875.8,
E875.9, E876.0 – E876.2, E876.5 – E876.9, E878.2 – E878.6, E879.0 – E879.4, E879.7 – E879.9, E930.0,
E930.1, E930.4 – E930.8, E931.1 – E931.5, E931.8, E931.9, E932.0 – E932.2, E932.5 – E932.9, E933.2 –
E933.6, E933.9, E934.0 – E934.3, E934.6 – E934.9, E935.0, E935.3 – E935.7, E936.0 – E936.4, E937.2 –
E937.4, E937.5, E937.6, E938.0 – E938.4, E938.7, E938.9, E939.0 – E939.2, E939.5 – E939.9, E940.8,
E940.9, E941.0 – E941.2, E942.0 – E942.4, E942.7 – E942.9, E943.0, E943.1, E943.4 – E943.6, E943.8,
E943.9, E944.2 – E944.6, E945.1 – E945.5, E945.8, E946.0 – E946.3, E946.6 – E946.9, E947.0, E947.3,
E947.4, E947.8, E947.9, E948.0, E948.3 – E948.6, E948.8, E949.1 – E949.5, and E949.9.
• ICD-10 codes
• D52.1, D59.0, D59.2, D59.6, D69.5, D78.2, D78.8, E03.2, E06.4, E09.0 – E09.4, E09.6, E09.8, E27.3,
E36.0, E36.1, E66.1, E89.0, E89.1, E89.3, E89.8, G24.0, G25.1, G25.6, G25.7, G93.7, G97.0, G97.1 –
G97.5, G97.9, I97.4, J95.8, K43.0 – K43.4, K43.7, K43.9, K91.5, K91.6, K94.1 – K94.3, K95.0, K95.8,
M87.1, N99.5, N99.6, N99.8, R50.2, R50.8, Y40.1 –Y40.4, Y40.7, Y43.4, Y44.5, Y45.0, Y45.1, Y45.4,
Y46.0, Y46.2 – Y46.4, Y48.2, Y49.2, Y49.8, Y51.3, Y51.4, Y52.0, Y52.4, Y52.5, Y53.8, Y53.9, Y54.6, Y55.3,
Y57.5, Y57.9, Y58.5, Y59.0, Y59.1 –Y59.3, Y59.8, Y59.9, Y60.5 – Y60.7, Y60.9, Y62.0, Y62.6, Y63.1,
Y63.2, Y63.5, Y64.0, Y65.1, Y65.3, Y65.5, Y65.8, Y70.0, Y70.1, Y73.2, Y74.0, Y75.1 –Y75.3, Y76.8, Y76.9,
Y78.3, Y79.8, Y80.2, Y80.3, Y81.2, Y81.8, Y82.1, Y83.0, Y83.4 –Y83.6, Y83.8, Y84.0, Y84.1, Y84.3 –
Y84.7, Y88.3.
Methods 12

13. Geographies
The UK was compared with 32 high-income countries:
• 4 Asia Pacific countries: Brunei, Japan, Singapore, South Korea
• 2 Australasia countries: Australia, New Zealand
• 2 North America countries: Canada, US
• 3 Southern Latin America countries: Argentina, Chile, Uruguay
• 21 Western Europe countries: Andorra, Austria, Belgium, Cyprus,
Denmark, Finland, France, Germany, Greece, Iceland, Ireland, Italy, Israel,
Luxembourg, Malta, Netherlands, Norway, Portugal, Spain, Sweden, and
Switzerland
Methods 13

14. Geographies:
division of England into 9 statistical regions
Methods
East of England
East Midlands
Greater London
North East
North West
South East
South West (historic)
West Midlands
Yorkshire & The
Humber
14

15. Estimated population size for the constituent countries of the UK
and the English regions in mid-1990 and mid-2013, at 30 June
OfficeforNationalStatistics,NationalRecordsofScotland,NorthernIrelandStatisticsandResearchAgency
Men Women Grand total
1990 2013 1990 2013 1990 2013
England
23,212,113
26,533,969
24,487,003
27,331,848
47,699,116
53,865,817
East
2,495,643
2,929,462
2,592,319
3,024,707
5,087,962
5,954,169
East Midlands
1,959,883
2,268,092
2,033,093
2,330,637
3,992,976
4,598,729
London
3,282,257
4,165,335
3,516,529
4,251,200
6,798,786
8,416,535
North East
1,252,760
1,278,454
1,331,560
1,332,027
2,584,320
2,610,481
North West
3,304,030
3,495,013
3,525,363
3,608,247
6,829,393
7,103,260
South East
3,703,280
4,323,690
3,894,777
4,468,936
7,598,057
8,792,626
South West
2,262,074
2,640,378
2,406,115
2,737,217
4,668,189
5,377,595
West Midlands
2,560,061
2,803,569
2,658,344
2,871,143
5,218,405
5,674,712
Yorkshire and
The Humber
2,392,125
2,629,976
2,528,903
2,707,734
4,921,028
5,337,710
Northern Ireland
777,884
897,145
817,711
932,580
1,595,595
1,829,725
Scotland
2,443,865
2,586,532
2,637,405
2,741,168
5,081,270
5,327,700
Wales
1,384,677
1,515,227
1,476,835
1,567,185
2,861,512
3,082,412
UK
27,818,538
31,532,873
29,418,954
32,572,781
57,237,493
64,105,654
Methods 15

16. Geography: 5 deprivation levels, England
• 32,844 neighborhoods / areas (LSOA) based on IMD, England
• Index of Multiple Deprivation (IMD) 2010 - 7 domains:
1. income (22.5% weighting)
2. employment (22.5%)
3. health & disability (13.5%)
4. education, skills & training (13.5%)
5. barriers to housing & services (9.3%)
6. living environment (9.3%)
7. crime (9.3%)
• Each region = 5 deprivation groups
• 5 deprivation groups × 9 regions = 45 deprivation areas
• 45 geographical areas = LEVELS OF DEPRIVATION 1 – 5
Methods 16

17. Methods: map of distribution of the IMD, 2015 (Department of Communities and Local Government)17

18. Estimates & arts
• The means with 95%UI for ASI & ASM for the UK & 32
countries
• The means with 95% UI for deaths, death & DALY rates per
100,000 individuals of all ages a year for England
• Percentage difference between 2 values at the same time
points
• Percentage change between 2 values at different points in time
• Graphs were created in Excel, transported to PDF and edited
using EPS software
Methods 18

19. Objective No. 1
• Incidence & mortality, 1990 - 2013
levels,
trends,
patterns
comparisons
• UK
• England, Scotland, Wales, N. Ireland
• the nine English regions
• 32 high-income countries
Results: 19

20. Incidence
Results 20

21. Incident cases with 95% UI ofAEs of medical treatment in the
UK in1990 and 2013, by gender and geographical region
Men Women
1990 2013 1990 2013
East of England 4363 (3993 - 4742) 5140 (4687 - 5566) 4489 (4148 - 4925) 5307 (4840 - 5747)
East Midlands 3422 (3136 - 3724) 3953 (3629 - 4309) 3538 (3253 - 3863) 4054 (3729 - 4428)
Greater London 5813 (5252 - 6236) 7401 (6665 - 7914) 6088 (5626 - 6681) 7346 (6802 - 8077)
North East 2183 (2004 - 2380) 2261 (2046 - 2429) 2293 (5641 - 6698) 2295 (2131 - 2531)
North West 5725 (5286 - 6278) 6119 (5592 - 6641) 6035 (5641 - 6698) 6285 (5773 - 6856)
South East 6404 (5925 - 7036) 7456 (6918 - 8215) 6839 (6232 - 7400) 7751 (7150 - 8491)
South West 3978 (3619 - 4297) 4674 (4225 - 5017) 4134 (3850 - 4572) 4766 (4380 - 5201)
West Midlands 4517 (4096 - 4864) 4926 (4486 - 5327) 4660 (4253 - 5051) 5030 (4593 - 5455)
Yorkshire and The
Humber 4195 (3827 - 4545) 4633 (4208 - 4997) 4358 (4046 - 4805) 4685 (4332 - 5145)
Northern Ireland 1368 (1245 - 1478) 1590 (1435 - 1705) 1412 (1308 - 1554) 1627 (1492 - 1772)
Scotland 4279 (3910 - 4643) 4553 (4138 - 4914) 4585 (4220 - 5011) 4856 (4386 - 5208)
Wales 2442 (2215 - 2631) 2655 (2424 - 2879) 2573 (2363 - 2806) 2733 (2507 - 2978)
UK 48690 (47292 - 50073) 55368 (53606 - 56759) 51006 (50012 - 52954) 56671 (55374 - 58631)
Results: Incidence 21

22. MeanASIR by geography, gender, and year:
175 and 176 in men, 173 and 174 in women
Results: Incidence 22

23. Mean ASIR by geography, gender & years 1990, 2013:
175 and 176 in men, 173 and 174 in women
Results: Incidence 23

24. SimilarASIRs with 95% UIs forAEs of medical treatment in 2013
(the US, Canada, & the Netherlands are exceptions)
Results: Incidence - comparisons and ranking of countries 24

25. Results: Incidence by age and gender
Trends from age-specific incidence rates for AEs of medical treatment per
100,000 individuals in 1990 and 2013, by gender, UK
25

26. Interim summary: incidence, 1990-2013
1. Varied minimally, UK
2. Significantly higher in the US, Canada, the Netherlands
3. Stability in incidence is a global phenomenon
Discussion: Incidence 26

27. Mortality
Results 27

28. Deathsand age-standardisedmortalityrates (ASMR)with 95% UI and percentagechangefromAEsof
medicaltreatment in men and women combinedin the UKin 1990 and 2013, by regionalgeography
of Englandand a constituentcountryof the UK
Deaths in 1990 Deaths in 2013 Percentage
change
ASDR per
100,000 in 1990
ASDR per
100,000 in 2013
Percentage
change
East 93.33
(64.4 to 112.2)
90.95
(69.15 to 133.58)
–2.6 1.26
(0.88 to 1.5)
0.82
(0.63 to 1.17)
–34.9
East Midlands 74.93
(54.19 to 92.79)
71.74
(54.59 to 103.59)
–4.3 1.33
(0.96 to 1.62)
0.89
(0.69 to 1.25)
–33.1
Greater London
124.51
(87.64 to 147.68)
89.91
(65.53 to 127.27)
–27.8 1.35
(0.96 to 1.58)
0.85
(0.65 to 1.25)
–37.0
North East
55.49
(39.75 to 67.27)
48.75
(36.55 to 70.6)
–12.1 1.55
(1.12 to 1.88)
1.05
(0.8 to 1.49)
–32.3
North West
135.44
(92.27 to 162.13)
108.48
(82.56 to 151.96)
–19.9 1.38
(0.97 to 1.63)
0.9
(0.7 to 1.25)
–34.8
South East
127.41
(86.63 to 151.06)
116.08
(86.99 to 166.58)
–8.9 1.08
(0.76 to 1.27)
0.72
(0.54 to 1.01)
–33.3
South West
79.91
(54.13 to 96.07)
75.44
(57.52 to 104.17)
–5.6 1
(0.69 to 1.18)
0.68
(0.53 to 0.93)
–32.0
West Midlands
105.9
(75.16 to 128.16)
100.56
(75.99 to 136.71)
–5.0 1.49
(1.07 to 1.8)
1.03
(0.79 to 1.41)
–30.9
Yorkshire and The
Humber
93.78
(64.17 to 112.18)
77.47
(60.92 to 116.4)
–17.4 1.32
(0.92 to 1.56)
0.86
(0.68 to 1.26)
–34.9
England 890.7
(644.41 to 999.76)
776.39
(645.07 to 1,045.15)
–12.7 1.28
(0.94 to 1.44)
0.85
(0.7 to 1.14)
–33.6
Northern Ireland
15.92
(12.31 to 20.04)
18.4
(14.18 to 24.46)
13.5 0.84
(0.65 to 1.05)
0.68
(0.53 to 0.91)
–19.1
Scotland
137.94
(108.35 to 174.1)
159.49
(105.54 to 194.22)
13.5 1.99
(1.56 to 2.48)
1.73
(1.18 to 2.1)
–13.7
Wales
53.61
(37.64 to 64.25)
49.46
(37.28 to 69.95)
–7.7 1.24
(0.88 to 1.47)
0.87
(0.68 to 1.19)
–29.8
UK
1,098.17
(805.99 to 1,236.6)
1,003.75
(815.75 to 1,302.58)
–8.6 1.33
(0.99 to 1.5)
0.92
(0.75 to 1.2)
–30.8
Results: Mortality 28

29. Variations in age-standardised mortality rates per 1,000,000 individuals fromAEs
of medical treatment by regional geography of the UK, gender, and year
datasortedindescendingorderformenfortheyear1990
0
5
10
15
20
25
Mortalityrateper1,000,000individuals
Men, 1990
Men, 2013
Women, 1990
Women, 2013
Results: Mortality 29

30. Decline in age-standardised mortality rates from adverse effects of medical
treatment for individuals of both sexes combined in 1990 and 2013
datasortedindescendingorderfortheyear2013
Results: Mortality 30
0
5
10
15
20
25
Mortalityrateper1,000,000individuals
1990
2013

31. Significant variations inAS-mortality rates (× 0.0001) fromAEs with 95% UI per
person in 2013, by gender and high-income country
estimatessortedbyascendingmortalityratesinmen
Results: Mortality comparisons 31

32. Pattern of age-specific mortality rates fromAEs by gender in 1990 and 2013, UK
-20
30
80
130
180
230
Mortalityrateper1,000,000individuals
Age
Men, 1990
Men, 2013
Women, 1990
Women, 2013
Results: Mortality by age and gender 32

33. Distribution of percentage differences from age-specific mortality fromAEs rates
in men and women with exponential trend-line, UK, 2013
NB! Mortality rates are higher in all age groups in men
Results: Mortality by age and gender 33

34. Interim summary: mortality,1990-2013
• The decline in mortality by 30.8%: indicates the progress
• Varied by the regional geography
• Disparities persist between North & South England,
Scotland and England
• The UK is performing worse 10-fold than Switzerland
• A factor of gender: men die more often than women
Results: Mortality 34

35. Survival
Results 35

36. Variations in the ratio from the mortality rate (M) to incidence rate (I) expressed
as 1 - M/I, by geography of the UK and gender, 2013
datasortedindescendingorderforwomen
Results: 1 – M/I ratio by age and gender 36
0.984
0.986
0.988
0.99
0.992
0.994
0.996
0.998
1-M/Iratio
Females
Males

37. Variations in the ratio from mortality rate to incidence rate expressed as 1 – (M/I)
by high-income country and gender, in 2013;
datasortedindescendingorderforwomen
Results: 1 – M/I ratio by age and gender 37
0.955
0.96
0.965
0.97
0.975
0.98
0.985
0.99
0.995
1
Switzerland
Singapore
Finland
NewZealand
Norway
Brunei
Malta
Denmark
Netherlands
Sweden
Japan
Iceland
Canada
Italy
Andorra
Ireland
UK
Austria
Germany
SouthKorea
Cyprus
Portugal
Spain
Greece
Australia
Chile
Uruguay
Belgium
France
Argentina
Israel
1-(Mortality/Incidence)ratio
Females
Males

38. Interim summary: a factor of geography
• Scotland - highest burden from AEs / UK
• NE of England: highest burden from AEs / England
• Switzerland, Singapore & Finland: the best performing
Discussion: Survival 38

39. Objective No. 2
• An analogy between socioeconomic
deprivation level & loss of health from AEs
in England
• Metrics
• Number of deaths
• Death rates
• DALY rates
Results 39

40. Adistinct pattern of disproportional distributions of deaths fromAEs in 100% stacked
column chart for five levels of deprivation in England between 1990 and 2013.
Thenumbersofdeaths(asthemeans)displayedin30color-codedfractionsofthecolumns.Level1=mostdeprived,
Level3=moderatedeprived,Level5=leastdeprived
Results: Deaths from AEs 40

41. Death rates with 95% UIs fromAEs per 100,000 all age individuals of both genders
combined in England and the English regions in 1990 and 2013, by level 1 (most deprived)
and level 5 (least deprived)
1990 Percentage
difference
2013 Percentage
difference
Level 1
(most deprived)
Level 5
(least deprived)
Level 1
(most deprived)
Level 5
(least deprived)
England 2.27
(1.65 to 2.57)
1.22
(0.88 to 1.38)
60.17 1.54
(1.28 to 2.08)
1.17
(0.97 to 1.59)
27.31
East of England 1.99
(1.32 to 2.39)
1.16
(0.8 to 1.4)
52.7 2.08
(1.56 to 3.16)
0.95
(0.73 to 1.38)
74.59
East Midlands 2.23
(1.54 to 2.77)
1.16
(0.79 to 1.46)
63.13 1.97
(1.49 to 2.89)
1.28
(0.96 to 1.89)
42.46
Greater London 2.11
(1.52 to 2.49)
1.37
(0.93 to 1.63)
42.53 0.97
(0.74 to 1.39)
1.09
(0.81 to 1.65)
11.65
North East of
England
2.76
(1.98 to 3.36)
0.75
(0.53 to 0.95)
114.53 1.77
(1.33 to 2.53)
1.13
(0.86 to 1.61)
44.14
North West of
England
2.23
(1.49 to 2.65)
1.67
(1.08 to 2.08)
28.72 1.61
(1.23 to 2.3)
1.53
(1.15 to 2.14)
5.1
South East of
England
2.37
(1.63 to 2.83)
1.02
(0.69 to 1.22)
79.65 1.64
(1.23 to 2.28)
1
(0.75 to 1.39)
48.48
South West of
England
1.37
(1 to 1.61)
1.29
(0.87 to 1.55)
6.02 1.45
(1.11 to 1.99)
1.17
(0.89 to 1.62)
21.37
West Midlands 2.41
(1.73 to 2.95)
1.18
(0.85 to 1.51)
68.52 1.88
(1.4 to 2.5)
1.64
(1.22 to 2.28)
13.64
Yorkshire and The
Humber
2.4
(1.64 to 2.84)
1.61
(1.05 to 1.98)
39.4 1.39
(1.1 to 2.06)
1.32
(1.04 to 2)
5.17
Results: Deaths rates from AEs 41

42. Trends for all age death rates per 100,000 individuals of both genders combined
in England by deprivation level from 1990 to 2013.
Level1=mostdeprived,Level3=moderatedeprived,Level5=leastdeprived 27.31%
Results: Deaths rates from AEs 42

43. Inequalities in trends for DALYrates per 100,000 men and women of all ages in
England by deprivation level from 1990 to 2013
level1=mostdeprived,3=moderatedeprived,andlevel5=leastdeprived
Results: DALY rates from AEs 43

44. Percentageproportionsin100%stackedbarchartfromthemeanDALYratesforlevel1(mostdeprived)andlevel5(least
deprived)areasacrossnineregionsofEnglandandforEnglandper100,000womenandmenofallagesin2013.
DominationofbluecolourbarsoverredcolourbarsshowsthatDALYrelatedburdenfromAEs inmostdeprived
populationsofEngland(level1)isdistinctfromleastdeprivedpopulations(level5)
Results: DALY rates from AEs 44

45. What this study adds
1. Despite gains in reducing mortality from AEs in the UK,
progress has not been achieved in the reduction of
incidence from AEs between 1990 and 2013
2. A direct link between deprivation level & health loss
from AEs in England & the English regions is apparent,
though vary, between most deprived & least deprived
3. DEPRIVATION LEVEL MATTERS on outcomes from AE
Conclusions 45

46. Incidence ofAEs remains the same, 1990-2013
Deprivation level matters
The take-home messages 46

47. Declarations & Acknowledgments
• Transparency declaration
• I affirm that the manuscript is an honest, accurate, and transparent account of the
study being reported
• Funding
• This study had no specific funding
• The Bill & Melinda Gates Foundation is sponsor of GBD project
• I would like to thank
• Mr Richard Ward, former Medical Director, Aintree, England
• Ms Julie Mcharron, Clinical Coding Auditor, Aintree, England
• Mr Paul Flynn, Divisional Governance, Aintree, England
• Ms Lynne Conde, General Surgery Department, Aintree, England
47
Thank you