national confidential enquiry into patient outcome and death

Improving the quality of medical and surgical care

National Confidential Enquiry into Patient Outcome and Death


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


Remit

We aim to review medical clinical practice and

to make recommendations to improve the

quality of the delivery of care.


Remit

We do this by undertaking confidential surveys

covering many different aspects of medical care

and making recommendations for clinicians and

management to implement.


Governance

• Independent

• Charity and company limited by guarantee

• 6 Trustees

• Chairman – Professor Tom Treasure


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


NCEPOD Observers

• NPSA

• Coroners Society

• Institute of Healthcare Management

• Scottish Audit of Surgical Mortality


Structure

• 11 Non-clinical staff

• 8 Clinical co-ordinators

• 550+ Local reporters


Coverage

• England

• Wales

• Northern Ireland

• Offshore Islands

• Independent sector


Participation

• NHS trusts mandated by ‘A first class service’

• Doctors mandated by ‘Good Medical Practice’


Confidentiality

• BS 7799

• PIAG

• DPA

• NRES

• Anonymisation


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


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


Method

• Results are confidential

• Cause for concern cases

• Feedback

– Organisational

– Clinical


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


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)


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


Key improvements

• 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)

WOW I 1997 WOW II 2003


Key improvements

• An Acute Problem

• Sedation

• Coroner’s Bill

• Trauma services


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.


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.


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.


Case study - prescribing errors


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.


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.”


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


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

national confidential enquiry into patient outcome and death

Documents