NCEPOD - Reports

Acute Heart Failure:
Failure to Function (2018)

This NCEPOD report highlights the process of care for patients aged 16 years or older who died in hospital following an admission with actute heart failure. The report takes a critical look at areas where the care of patients might have been improved. Remediable factors have also been identified in the clinical and the organisational care of these patients.

Chronic Neurodisability:
Each and Every Need (2018)

This NCEPOD report highlights the quality provided to children and young people with chronic disabling conditions, focusing in particular on cerebral palsies. The report takes a critical look at areas where the care of patients might have been improved. Remediable factors have also been identified in the clinical and the organisational care of these patients.

Acute Non-Invasive Ventilation:
Inspiring Change (2017)

This NCEPOD report highlights the quality of acute non-invasive ventilation clinical care, for patients aged 16 years or older who are admitted to hospital. The report takes a critical look at areas where the care of patients might have been improved. Remediable factors have also been identified in the clinical and the organisational care of these patients.

Mental Health in General Hospitals:
Treat as One (2017)

This NCEPOD report highlights the quality of mental health and physical health care for patients aged 18 years or older with a significant mental health condition who are admitted to a general hospital. The report takes a critical look at areas where the care of patients might have been improved. Remediable factors have also been identified in the clinical and the organisational care of these patients.

Acute Pancreatitis:
Treat the Cause (2016)

This NCEPOD report highlights the process of care forpatients aged 16 years or older with acute pancreatitis. The report takes a critical look at areas where the care of patients might have been improved. Remediable factors have also been identified in the clinical and the organisational care of these patients.

Sepsis:
Just Say Sepsis! (2015)

This NCEPOD report highlights the process of care for patients aged 16 years or older with sepsis. The report takes a critical look at areas where the care of patients might have been improved. Remediable factors have also been identified in the clinical and the organisational care of these patients.

Gastrointestinal Haemorrhage:
Time to Get Control? (2015)

This NCEPOD report highlights the process of care for patients aged 16 years or older that were coded for a diagnosis of GI haemorrhage. The report takes a critical look at areas where the care of patients might have been improved. Remediable factors have also been identified in the clinical and the organisational care of these patients.

Lower Limb Amputation:
Working Together (2014)

This NCEPOD report highlights the process of care for patients aged 16 and over who undergo lower limb amputation. The report takes a critical look at areas where the care of patients might have been improved. Remediable factors have also been identified in the clinical and the organisational care of these patients.

Tracheostomy Care:
On the Right Trach? (2014)

This NCEPOD report highlights the process of care for patients who undergo the insertion of a new tracheostomy or a laryngectomy. The report takes a critical look at areas where the care of patients might have been improved. Remediable factors have also been identified in the clinical and the organisational care of these patients.

Subarachnoid Haemorrhage:
Managing the Flow (2013)

This NCEPOD report highlights the process of care for patients who are admitted with with aneurysmal subarachnoid haemorrhage, looking both at patients that underwent an interventional procedure and those managed conservatively. The report takes a critical look at areas where the care of patients might have been improved. Remediable factors have also been identified in the clinical and the organisational care of these patients.

Alcohol Related Liver Disease:
Measuring the Units (2013)

This NCEPOD report highlights the process of care for patients treated for alcohol-related liver disease. The report takes a critical look at areas where the care of patients might have been improved and the degree to which its mortality is amenable to health care intervention. Remediable factors have also been identified in the clinical and the organisational care of these patients.

Bariatric Surgery:
Too Lean a Service? (2012)

This NCEPOD report highlights the process of care for patients aged over 16, who underwent bariatric surgery for weight loss. The report takes a critical look at areas where the care of patients might have been improved during the whole patient journey, from referral to follow up. Remediable factors have also been identified in the clinical and the organisational care of these patients.

Cardiac Arrest Procedures:
Time to Intervene? (2012)

This NCEPOD report highlights the process of care for patients aged 16 and over, who received cardiopulmonary resuscitation in an in-hospital setting. The report takes a critical look at areas where the care of patients might have been improved, and factors which may have affected the decision to initiate a resuscitation attempt.

Peri-operative Care:
Knowing the Risk (2011)

This NCEPOD report highlights the process of care for patients aged 16 and over, who underwent inpatient surgery (both elective and emergency), and their outcome at 30 days. The report takes a critical look at areas where the care of patients might have been improved.

Surgery in Children:
Are We There Yet? (2011)

This NCEPOD report highlights the process of care of children less than 18 years of age, including neonates who died within 30 days of emergency or elective surgery on the same admission. The report takes a critical look at areas where the care of patients might have been improved. Remediable factors have also been identified in the clinical and the organisational care of these patients.

Elective & Emergency Surgery in the Elderly:
An Age Old Problem (2010)

This NCEPOD report highlights the process of care of elderly patients who died within 30 days of emergency or elective surgery. It takes a critical look at areas where the care of patients might have been improved. Remediable factors have been identified in the clinical and the organisational care of these patients.

Cosmetic Surgery:
On the face of it (2010)

This NCEPOD report reviews variations in organisational structures surrounding the practice of cosmetic surgery and takes a critical look at areas that have been identified where the organisation of care of cosmetic surgery patients can be improved. It investigates policies surrounding advertising and consent; the structure and case-mix of teams providing cosmetic surgery, the number and types of procedures performed; the provision of post-operative follow-up; policies, facilities and protocols and policies for clinical audit.

Parenteral Nutrition:
A Mixed Bag (2010)

This NCEPOD report highlights the process of care of patients who receive Parenteral Nutrition. These are patients with a compromised nutritional status, where oral or enteral feeding is not an option. The report takes a critical look at areas where the care of patients might have been improved. Remediable factors have been identified in the clinical and the organisational care of these patients.

Deaths in Acute Hospitals:
Caring to the End? (2009)

This NCEPOD report highlights the process of care of patients who died in acute hospitals within four days of admission. It takes a critical look at areas where the care of patients might have been improved. Remediable factors have been identified in the clinical and the organisational care of these patients.

Acute Kidney Injury:
Adding Insult to Injury (2009)

This NCEPOD report highlights the process of care of patients who died in hospital with a primary diagnosis of acute kidney injury (AKI). It takes a critical look at areas where the care of patients might have been improved. Remediable factors have been identified in the clinical and the organisational care of these patients.

Systemic Anti-Cancer Therapy:
For better, for worse? (2008)

This NCEPOD report highlights the process of care of patients who died within 30 days of receiving systemic anti-cancer therapy (SACT). It takes a critical look at areas where the care of patients might have been improved. Remediable factors have been identified in the clinical and the organisational care of these patients.

Coronary Artery Bypass Grafts:
The heart of the matter (2008)

This NCEPOD report analyses the care of a sample of patients who in the majority did not survive to leave hospital following their CABG operation. It takes a critical look at the selection of the surgery and the strategy and the organisational factors involved in its implementation.

Sickle: A sickle crisis? (2008)

NCEPOD was pleased to undertake a review of current haemoglobinopathy mortality, to obtain broad baseline data and make recommendations to alter practice. In this way, we hope to contribute to improving the quality of life of patients - whose numbers and attendances at health care centres are inevitably going to increase.

Trauma:
Who Cares? (2007)

This study shows a rounded picture of current trauma care provision in England, Wales, Northern Ireland and the Offshore Islands. It draws on data provided by the clinicians involved in the care of these patients (from questionnaires) and data extracted from the casenotes. However, these data are accompanied by peer review, by practising clinicians involved in the day-to-day care of trauma patients, to give a much richer picture than a purely quantitative assessment would allow.

Emergency Admissions:
A journey in the right direction? (2007)

In this study, NCEPOD has assessed organisational and clinical aspects of both the immediate and ongoing care of patients admitted as emergencies. The report highlights remediable factors in existing care pathways, particularly the appropriateness, timeliness and frequency of investigations and reviews, the experience of staff and the availability of results, protocols and procedures.

The Coroner's Autopsy:
Do we deserve better? (2006)

Following a proposal from the Royal College of Pathologists, NCEPOD has reviewed, in detail, the autopsy reports produced for the coroners; this includes both deaths in hospitals and in the community.

Abdominal Aortic Aneurysm:
A service in need of surgery? (2005)

Abdominal aortic aneurysm is a life threatening condition and once a decision has been made to operate, this should be carried out as expeditiously as possible. In patients scheduled for elective major vascular surgery, numerous factors contribute to delays, not least of which is the availability of high dependency and intensive care facilities.

An acute problem? (2005)

"An Acute Problem?" is the second study related to our enlarged responsibility for including medical cases. It has been designed to link together the provision of critical care facilities with the care of severely ill medical patients throughout our hospitals. The pattern of inpatient care is changing rapidly and NCEPOD's role is to facilitate and inform that change. This study is as much about facilities and resources as about clinical practice and highlights the levels of care appropriate to patient requirements.

Scoping our practice (2004)

Although GI endoscopy as a specialty has produced good guidelines on training, the report highlights the need for national guidelines to assure continuing competence in endoscopy, particularly for those practitioners who only perform a small number of procedures each year. If we are to significantly improve the outcome of patients undergoing therapeutic endoscopy this report gives us many clear indications and recommendations about how this might be achieved.

Who operates when? II (2003)

The first 'Who Operates When?' (WOW I) report was published in 1997 and considerable changes have occurred in the staffing and surgical activity of hospitals since that time. This report again reinforces the need for sufficiently robust information and data collection systems in every Trust. Although this is often believed to be primarily necessary for producing accurate activity data, it is becoming increasingly important in clinical governance, risk management and other indices of morbidity and mortality.

Functioning as a team? (2002)

National CEPOD has repeatedly emphasised the need for the development of multi-professional and multidisciplinary teams to provide optimum care for the most seriously ill patients. In this report, based on deaths within three days of an intervention, NCEPOD looks at how far team working has developed and, most particularly, at weaknesses in the systems which create barriers to change.

Changing the way we operate (2001)

This report provides a stark comparison of the changing medical scene over the past decade. It demonstrates that patients being subjected to emergency surgery are both older and sicker than they were ten years ago. In turn, this has a profound impact on the service provision necessary to deal with these clinical problems.

Then and now (2000)

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.

Percutaneous transluminal coronary angioplasty (2000)

This is a small survey by NCEPOD standards, but one of great importance, and demonstrates the value of the acquisition of reliable data by clinicians involved, and the importance of recording this on a national level to assess the quality of outcomes.

Interventional vascular radiology and interventional neurovascular radiology (2000)

Significant advances in interventional techniques, particularly in vascular and neurovascular radiology, in the last decade have led NCEPOD to explore the morbidity and mortality associated with such procedures. In view of the frequency with which these minimally invasive techniques are being carried out, it is important that the consequences of such interventions should be investigated.

Extremes of Age (1999)

This report concentrates on the extremes of age. In detail there are obvious differences between the groups, yet many of the lessons to be drawn from this study span the age difference.

The 1996/7 Report of NCEPOD)

In this report recommendations were made with reference to specific surgical procedures: gynaecological surgery; head and neck surgery; minimally invasive surgery; oesophageal surgery; spinal surgery; urological surgery.

The 1995/6 Report of NCEPOD - Who Operates When?

This original report reviewed all surgical procedures during a one week period to identify the grades of surgeons operating and when the surgery was performed. This report led to the introduction of 'CEPOD' theatres.

The 1994/5 Report of NCEPOD

This report focussed on the first perioperative death, within three days of surgery, reported for each surgeon or gynaecologist.

The 1993/4 Report of NCEPOD

This report focussed on the first perioperative death reported for each surgeon or gynaecologist.

The 1992/3 Report of NCEPOD

This report was similar to the 1991/1992 report but looked at a sample of perioperative deaths in people aged 6 to 70 years.

The 1991/2 Report of NCEPOD

This report covered the largest sample to date. The study included all perioperative deaths of patients aged 6 to 70 years.

The 1990 Report of NCEPOD

This report provided results on the review of a random 20% sample of patients over the age of 10 who died perioperatively.

The 1989 Report of NCEPOD

The 1989 report of the National Confidential Enquiry into Perioperative Deaths highlighted the standard of surgical and anaesthetic care received by children.

The 1987 Report of NCEPOD

The first report of the National Confidential Enquiry into Perioperative Deaths highlighted the standard of surgical and anaesthetic care received by patients.

Reports

Acute Heart Failure:Failure to Function (2018)

Chronic Neurodisability:Each and Every Need (2018)

Acute Non-Invasive Ventilation:Inspiring Change (2017)

Mental Health in General Hospitals:Treat as One (2017)

Acute Pancreatitis:Treat the Cause (2016)

Sepsis:Just Say Sepsis! (2015)

Gastrointestinal Haemorrhage:Time to Get Control? (2015)

Lower Limb Amputation:Working Together (2014)

Tracheostomy Care:On the Right Trach? (2014)

Subarachnoid Haemorrhage:Managing the Flow (2013)

Alcohol Related Liver Disease:Measuring the Units (2013)

Bariatric Surgery:Too Lean a Service? (2012)

Cardiac Arrest Procedures:Time to Intervene? (2012)

Peri-operative Care:Knowing the Risk (2011)

Surgery in Children:Are We There Yet? (2011)

Elective & Emergency Surgery in the Elderly:An Age Old Problem (2010)

Cosmetic Surgery:On the face of it (2010)

Parenteral Nutrition:A Mixed Bag (2010)

Deaths in Acute Hospitals:Caring to the End? (2009)

Acute Kidney Injury:Adding Insult to Injury (2009)

Systemic Anti-Cancer Therapy:For better, for worse? (2008)

Coronary Artery Bypass Grafts:The heart of the matter (2008)