National Confidential Enquiry into Patient Outcome and Death

1. National Confidential Enquiry into Patient Outcome and Death

2. History • Report of a Confidential Enquiry into Perioperative Deaths -published Dec 1987 • Became the National Confidential Enquiry into Patient Outcome and Death in 2003 • Contract managed by NPSA from April 2005

3. Remit We aim to review medical clinical practice and to make recommendations to improve the quality of the delivery of care.

4. Remit We do this by undertaking confidential surveys covering many different aspects of medical care and making recommendations for clinicians and management to implement.

5. Governance • Independent • Charity and company limited by guarantee • 6 Trustees • Chairman – Professor Tom Treasure

6. NCEPOD Supporting bodies Faculty of Public Health Medicine of RCP Association of Anaesthetists Association of Surgeons Royal College of Anaesthetists Royal College of Radiologists Royal College of Ophthalmologists Royal College of Surgeons Lay Representatives Faculty of Dental Surgery of RCS Royal College of Pathologists Royal College of Obstetricians & Gynaecologists Royal College of Physicians Royal College of General Practitioners Royal College of Nursing Royal College of Child Health and Paediatrics

7. NCEPOD Observers NPSA Coroners Society Institute of Healthcare Management Scottish Audit of Surgical Mortality

8. Structure 11 Non-clinical staff 8 Clinical co-ordinators 550+ Local reporters

9. Coverage England Wales Northern Ireland Offshore Islands Independent sector

10. Participation NHS trusts mandated by ‘A first class service’ Doctors mandated by ‘Good Medical Practice’

11. Confidentiality • BS 7799 • PIAG • DPA • NRES • Anonymisation

12. Method • Expert group • Identify study questions – literature search • Pilot study – HES • Run main study - ONS • Primary data set • One or more clinical questionnaires • Extracts of the casenotes • Organisational questionnaire

13. Method • Anonymisation • Advisors review each case - qualitative • Questionnaires analysed – quantitative • All findings and recommendations are reviewed by the Expert group • All drafts of the report are read twice by the Steering Group • Report launched

14. Method • Results are confidential • Cause for concern cases • Feedback • Organisational • Clinical

15. Reports • Reports published mainly around deaths within 30 days of a surgical procedure But with some variations • Therapeutic endoscopy • Medical admissions into intensive care • Abdominal aortic aneurysms • Coronial autopsies • Emergency admissions

16. Recommendations • Every report of NCEPOD has contained a recommendation relating to poor information systems e.g. • “The provision of clinical and management information about patients, including post mortem records needs to be improved significantly” (1990 report) • “All trusts in the NHS should use information systems with a nationally agreed specification. This should apply to casenotes, patient information systems etc. Such uniform systems would facilitate the retrieval of standardised information and ease the introduction of the electronic paper record”. (2001) • Documentation of the first consultant review should be clearly indicated in the casenotes and should be subject to local audit. (2007)

17. Key improvements • Improved provision of surgical, anaesthetic and critical care facilities • More involvement of senior staff • Better supervision of trainees • Better communication • Reduction in inappropriate out of hours surgery • More specialisation particularly for children

18. Key improvements WOW I 1997 WOW II 2003 • 20% operations OOH by SHO • 47% anaesthetics OOH by SHO • 51% hospitals had “CEPOD” theatres • 6% operations OOH by SHO • 25% anaesthetics OOH by SHO • 63% hospitals had “CEPOD” theatres (Further improvement to 77% identified in later report)

19. Key improvements • An Acute Problem • Sedation • Coroner’s Bill • Trauma services

20. Case study - lack of consultant input 75 year old with diarrhoea and malaise admitted by SHO. BP 110/60 P100 RR 36. The working diagnosis “?Infection”. IV fluids and antibiotics were given and the BP 85/50 persisted for 24 hours with IV fluids. All reviews were by HO or SHO with no consultant input. By 48 hours BP 70/30 anuric and comatose. The SHO diagnosed septic shock and eventually referred the patient to ICU. The patient died 12 hours later.

21. Case study - missing casenotes Following investigation with a barium enema and endoscopy, a carcinoma of the colon with complete obstruction was diagnosed. Two weeks later the patient was admitted with lower abdominal pain and constipation. The previous notes and X-rays were not available nor was the patient clear about their condition. The surgical team caring for the patient on this occasion was therefore unaware of the diagnosis and no operation was performed. A few days later the patient perforated their bowel and was taken to the operating theatre but the clinicians had still not seen the original notes or X-rays.

22. Case study - poor record keeping A 76-year-old , ASA 3 female without recognised co-existing medical disorders had a mastectomy and axillary clearance. Three days later she collapsed with diarrhoea, hypotension and hypoxia. There were no entries in the medical notes between her clerking on admission and this collapse, at which time the entry was “low BP all the time after mastectomy”. By this time the patient was in fast atrial fibrillation, dehydrated and in renal failure. Despite aggressive resuscitation she died later that day. The autopsy reported cardiac failure due to left ventricular hypertrophy and atrial fibrillation.

23. Case study - prescribing errors

24. Case study - communication The autopsy found nothing significant externally, apart from blood oozing from the nose. Internally the heart was normal and there was early bronchopneumonia in the right lung. The abdominal organs were normal and tablets/capsules were not seen in the stomach. The brain was normal and no significant abnormalities were seen in the musculo-skeletal system.

25. Case study - communication “ I have received further information that the deceased was found with a plastic bag over [their] head………in the absence of this information at the time of the post mortem I was unable to carry out some investigations which would have been done in the presence of this information. ……… Toxicology was not taken. I was not able to examine the bag. In my view there is no alternative but to submit a cause of death as: 1a. Unascertained.”

26. Studies in progress • Sickle cell and thalassaemia. Publication May 2008 • Coronary artery bypass grafting. Publication June 2008 • Systemic Anti-Cancer Therapy. Data collection underway. Publication November 2008 • Deaths in acute hospital. Early stages of development • Acute kidney injury

27. Future • Monitor changes in systems of care • Engage medical specialities • Maintain enthusiasm within surgery and anaesthesia • Ensure topic selection remains relevant to current practice • Ensure appropriate dissemination of learning points