News

The NCEPOD 2008 Report Launch of: "CABG: The heart of the matter"

The NCEPOD 2008 Report: "CABG: The heart of the matter" was launched on the 4th June 2008 at Regents College, London.

To view the report, please click here.

The NCEPOD 2008 Report Launch of: "Sickle: A sickle crisis?"

The NCEPOD 2008 Report: "Sickle: A sickle crisis?" was launched on the 21st May 2008 at the UK Forum on Haemogoblin Disorders at Guys Hospital.

To view the report, please click here.

NCEPOD's - Topic Selection - 2008

NCEPOD is inviting organisations or individuals to submit original study proposals for consideration as possible forthcoming studies. Study proposals should be relevant to the current clinical environment and have the potential to contribute original work to the subject.

Those wishing to submit a study proposal should complete the study proposal form and return it to NCEPOD by 26th September 2008. To download the study proposal form for submission please click here. The Adobe Acrobat reader is required which is free to download here.

For help on completing the form please see the example.

For further information on the process of topic selection please click here.

The NCEPOD 2007 Report Launch of: "Emergency Admissions: A journey in the right direction?"

The NCEPOD 2007 Report: "Emergency Admissions: A journey in the right direction?" was launched on Wednesday 10th October 2007 at the Royal College of Physicians.

To view the report, please click here.

The NCEPOD 2006 Report Launch: "The Coroner's Autopsy: Do we deserve better?"

The NCEPOD 2006 Report: "The Coroner's Autopsy: Do we deserve better?" was launched on Wednesday 18th October 2006 at the Royal College of Pathologists.

To view the report, please click here.

Elderly patients vulnerable because of excessive doses of sedatives.

Following on from our 2004 report 'Scoping Our Practice', an article has been written suggesting measures to prevent the over sedation of elderly patients.

To download the report please click here. The Adobe Acrobat reader is required which is free to download here.

Cardiac Arrest Procedures Study (Publication date: Early 2009)

Due to a number of reports, soon to be released, from the NPSA, NICE and the DH that will highlight the care of acutely ill patients, we are concerned that the proposed NCEPOD study of patients who suffer a cardiac arrest is untimely. Whilst it is undoubtedly an important study it will yield more useful results if it were performed at a later stage, once the above reports have bedded into clinical practice. Therefore we have taken the decision to postpone the NCEPOD study at this time, with the anticipation of revisiting the study at a more appropriate time.

Further questions about the study may be directed to: cardiacarrests@ncepod.org.uk

Systemic Anti-Caner Therapy Study (July 2006)

Systemic Anti Cancer Therapy Study NCEPOD is examining the process of care of all patients who die within 30 days of systemic anti-cancer therapy (SACT), looking for areas where their care might have been improved (remediable factors). The study will not concentrate solely on those patients who have a treatment-related death. The five main thematic areas that will be addressed in this study are: The appropriateness of the decision to treat with SACT; The process of prescribing and administration of SACT; The safety of the care with regard to monitoring of toxicity and management of complications; Communication - patient information, care pathways, protocols, guidelines, and MDT meetings; and Regular clinical audit with regard to process of care and clinical outcomes. All NHS and independent hospitals, and day centres, that treat patients with SACT in the National Health Service in England, Wales and Northern Ireland, and public hospitals in the Isle of Man, Jersey and Guernsey, as well as Defence Secondary Care Agency hospitals, will be included in the study. Data will be collected on all patients aged 16 years or over, who suffered from solid tumours and/or haematological conditions where systemic anti-cancer treatments were given during June and July 2006. Treatment types to be included in the study are intravenous, oral, subcutaneous, intravesical, intrathecal, or intraperitoneal chemotherapy, monoclonal antibodies, or cytokines. The case records of all patients who died within 30 days of SACT will be reviewed in detail. Clinical advisors required We are looking for appropriate clinicians e.g. medical/clinical oncologists, haemato-oncologists, surgical oncologists, pharmacists, and chemotherapy nurses, to form a multidisciplinary group of advisors to review the information and provide expert opinion on the patient care. You would typically be required to attend a 1-day meeting once a month at the NCEPOD offices in London, from June 2007 to February/March 2008. There would also be a training day in mid-June 2007. If you would be interested in acting as a clinical advisor for this study please send a copy of your CV including the names of two referees to cancertherapies@ncepod.org.uk or by post using our contact details by Tuesday 17th April 2007. For more information please refer to the the Current Studies section of this site.

Elderly patients vulnerable because of excessive doses of sedatives (Date ?)

Following on from our 2004 report 'Scoping Our Practice', an article has been written suggesting measures to prevent the over sedation of elderly patients.

To view the report, please click here. The Adobe Acrobat reader is required which is free to download here.

Press release from NCEPOD regarding the 2005 report - 'Abdominal Aortic Aneurysm: A service in need of surgery?' Published 26th October 2005

Press release from NCEPOD regarding the 2005 report 'Abdominal Aortic Aneurysm: A service in need of surgery?' Published 26th October 2005 Waiting Times for AAA Elective Surgery Criticised by NCEPOD NCEPOD calls for equal priority with other patients with serious clinical conditions and reorganisation of vascular services. Criticisms of long waiting times for patients requiring surgery for abdominal aortic aneurysms (AAA) have been made by the National Confidential Enquiry into Patient Outcome and Death (NCEPOD). In NCEPOD's latest report, Abdominal Aortic Aneurysm: A service in need of surgery?, the authors found that over a fifth of patients (21%) spent more than 12 weeks on the waiting list for elective AAA repair, despite the condition being described by NCEPOD's chairman, Dr Peter Simpson as “life threatening”. He adds: “Once a decision has been made to operate, this should be carried out as expeditiously as possible.” In the two month period studied, 18 patients admitted as an emergency had been on the waiting list for elective repair. The report states, “patients with aortic aneurysms face great uncertainty about how soon they will be treated, whilst knowing that their condition is life threatening. They know that if the aneurysm ruptures before admission the probability of survival is much reduced”. The report found that the mortality rate for elective surgery was 6.2% as opposed to 36% for those admitted as an emergency. All of the 47 patients who were treated with a new radiological technique called endovascular repair and where NCEPOD had data were alive, 30 days after the procedure. In the report, which was supported by the Vascular Society of Great Britain and Ireland, the Vascular Anaesthesia Society of Great Britain and Ireland, and the Royal College of Radiologists, the authors found that numerous factors contributed to the delays, not least the availability of high dependency (HDU) and intensive care (ICU) facilities, resulting in more than one in six elective patients having their operation postponed. NCEPOD is also calling for Trusts and Strategic Health Authorities to review whether elective aortic aneurysm surgery should be concentrated in fewer hospitals. However, for the emergency case, the risks of transferring an acutely ill patient with a leaking or ruptured aneurysm must be balanced against the risks of operative treatment in a less specialised and sometimes isolated hospital. Various solutions to this dilemma may be needed. The Study Data collection took place for two months from 1st February until 31st March 2004. 181 hospitals took part in the study. Of these 163 were NHS hospitals and 18 were private hospitals. Of the 181 hospitals, 137 completed at least one clinical questionnaire and 21 reported no cases for either month (an 87% participation). 884 cases were reviewed, 805 (91%) required surgery, and 79 (9%) were given palliative care. Of the operative cases, 53 (7%) underwent an endovascular procedure, and 752 (93%) underwent an 'open' procedure. Of this latter number 264 (35%) were emergencies and 434 (58%) were elective (the admission method in 7% was unknown). Main Findings & Recommendations included: Organisation of Vascular Services: Poor availability of radiology services out of hours was common Recommendation: Trusts should ensure the availability outside normal working hours of radiology services including CT scanners. Emergency arrangements: only 57% of hospitals reported a separate on-call rota for vascular surgery Recommendations: Clinicians, purchasers, Trusts and Strategic Health Authorities should review whether elective aortic aneurysm surgery should be concentrated in fewer hospitals. Post operative care: 9% of patients were reported to have been nursed in recovery areas for a substantial period after surgery Recommendation: Major elective surgery should not take place unless all essential elements of the care package are available. Surgery 21% of patients spent more than 12 weeks on the waiting list for elective AAA repair. 18 patients admitted as an emergency had been on the waiting list for elective repair. Recommendation: Patients with an aortic aneurysm requiring surgery must have equal priority with all other patients with serious clinical conditions for diagnosis, investigation and treatment One in 25 patients had their original operation cancelled because there was no ward bed available One in six had their original operation cancelled because there was no critical care bed available Recommendation: Trusts should take action to improve access to Level 2 beds for patients undergoing elective aortic aneurysm repair so as to reduce the number of operations cancelled and inappropriate use of Level 3 beds 15 emergency operations were performed without a consultant surgeon present. 16 emergency operations were performed by a surgeon without an elective vascular workload Recommendation: Strategic Health Authorities and Trusts should cooperate to ensure that only surgeons with vascular expertise operate on emergency aortic aneurysm patients, apart from exceptional geographical circumstances Endovascular repair All the patients on whom data was provided (47/53) were alive at 30 days

NPSA involvement

NPSA involvement From 1 April 2005 the National Patient Safety Agency (NPSA) has expanded, giving it greater scope to improve patient safety in the NHS. The NPSA helps the NHS learn from things that go wrong and develops solutions to prevent harm in the future. We do this by working with patients and staff locally and nationally to foster a culture where errors can be investigated and innovative solutions developed. We also do this by collecting and analysing information from staff and patients via our national reporting and learning system and other sources. From 1 April 2005, the NPSA's work also encompasses: safety aspects of hospital design, cleanliness and food (transferred from NHS Estates); ensuring research is carried out safely, through its responsibility for the National Research Ethics Service (NRES); and is supporting local organisations in addressing their concerns about the performance of individual doctors and dentists, through its responsibility for the National Clinical Assessment Service (NCAS), formerly known as the National Clinical Assessment Authority. It also manages the contracts with the three confidential enquiries. This responsibility has been transferred from the National Institute for Clinical Excellence (NICE). All contact addresses for these organisations remain the same and can be found here: The National Patient Safety Agency (NPSA) The National Clinical Assessment Service (NCAS) The National Research Ethics Service (NRES) The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) The Confidential Enquiry into Maternal and Child Health (CEMACH) The National Confidential Enquiry into Suicide and Homicide by people with mental illness (NCISH)

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