RECOMMENDATIONS

Patients must be assessed by the referring clinician and the endoscopist to justify that the procedure is in the patient’s interest. (Professional specialist associations)

The risks and benefits of therapeutic endoscopy should be explained to the patient, and this should be documented on the consent forms as laid down in the Department of Health guidelines. (Local hospitals)

The ability of those with dementia or acute confusion to provide consent should be tested and clearly documented. (Local hospitals)

There should be national guidelines for assuring continuing competency
in endoscopy. (Professional specialist associations)

All endoscopy units should perform regular audit and all deaths during, or within 30 days of, therapeutic endoscopy should be reviewed.
(Local hospitals; Professional specialist associations)

All those responsible for the administration of sedation should have received formal training and assessment. (Local hospitals)

Sedation and monitoring practices within endoscopy units should be audited and reviewed. (Local hospitals; Professional specialist associations)

There should be national guidelines on the frequency and method of the recording of vital signs during the endoscopy. (NPSA; Professional specialist associations)

Clear protocols for the administration of sedation should be available and implemented. (Local hospitals)

The decision to use a PEG feeding tube requires an in-depth assessment of the potential benefits to the individual. All patients in whom PEG feeding is proposed should be reviewed by a multidisciplinary team. (NICE)

There is a need for more comprehensive national guidelines for the use of PEG feeding, including issues of patient selection. (NICE)

Patients should be reviewed by the consultant endoscopist before therapeutic ERCP to ensure that the procedure is appropriate and that the patient’s condition has been optimised. (Local hospitals)

Only experienced endoscopists should treat patients with upper GI haemorrhage. Experience will vary by grade but competence should be assessed by the supervising consultant. (Local hospitals)

Optimising the patient’s pre-endoscopy condition will reduce both morbidity and mortality. Early involvement of an anaesthetist/intensivist if necessary, will assist this.
(Local hospitals)

A national audit across all specialties of specific techniques and equipment that is used for upper GI dilation and tubal prosthesis insertion is indicated. (NPSA)

The operative procedure should be included in the cause of death statement. (Undergraduate and post-graduate deans; ONS)

Post-procedure deaths (i.e. those occurring during or within 24 hours of anaesthesia or sedation or those where it is known that the procedure is implicated in the death) should be reported to the coroner. (Local hospitals)

Pathologists should think more carefully about all the clinical circumstances of a death,
to produce an autopsy report more useful for clinical governance and audit.
(Professional specialist associations particularly the Royal College of Pathologists)

NCEPOD supports the reforms of the ‘coronial system’ and death certification, which will result in better scrutiny of deaths. (Home Office)