The Department of Health report on learning from adverse events, 'An
Organisation with a Memory', commented upon the serious difficulty
in establishing the rate of change when good practice recommendations
are made by National Confidential Enquiries. This report, therefore,
covering a period of almost ten years enables us to evaluate
some of the changes that have occurred, but possibly more particularly
to highlight the issues where changes have been less than adequate
and certainly the rate of change has been unacceptably slow.
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Executive
Summary(175Kb) An Adobe Acrobat copy of the summary of this report is available to view/save.
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Individual Report
Sections
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here.
A. Glossary
B. Abbreviations
C. NCEPOD Corporate Structure
D. Data Collection & Review Method
E.
Local Reporters
F. Participants (anaesthetists)
G. Participants (surgeons & gynaecologists)
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