1. FUNCTIONING AS A TEAM? The 2002 Report of the National Confidential Enquiry into Perioperative Deaths

2. Study method April 2000 to March 2001 Deaths on day of or within 3 days of surgery First occurrence for each surgeon

3. Sample size Total deaths reported 21 991 Included 20 736 Excluded 1255 Died within 3 days 7184 (35%) Died between 4 & 30 days 13 552 (65%) Surgical Qs analysed 2114 Anaesthetic Qs analysed 1911

4. Reporting all deaths 70/216 trusts/groups> 25% difference in number of deaths from 99/00 46% of cases reported more than 3 months after death Approximate 4% of cases mis-reported Unable to trace consultant anaesthetist in 5% of sample cases

5. Facilities Questions previously in individual clinical questionnaires Information needed by hospital 81% return rate Data questionable in some cases

6. Recovery facilities Previous anecdotal evidence of delays caused to operating lists due to lack of recovery beds 237 hospitals had less than 1.5 recovery beds/theatre

7. Staffing of ICUs 32% had less than 7 sessions/week 12% of ICUs had no funded consultant sessions ICS guideline - 10 fixed + 5 flexible NCSC regulations - patients to be seen twice daily by consultant

8. Recommendation Management should ensure that an appropriate number of funded sessions for consultants trained in critical care are allocated to the ICU to allow appropriately qualified medical staff to be available to the ICU at all times

9. FUNCTIONING AS A TEAM? The 2002 Report of the National Confidential Enquiry into Perioperative Deaths

10. Age profile

11. ASA profile

12. Referrals to the surgical team 295 patients (14%) were transferred from another hospital before their final operation 402 (19%) were referred by a medical specialty in the same hospital

13. Preoperative care 88% (430/487) of hospitals reported pre-admission assessment clinics

14. Patients in this sample 234 of 356 day case or elective admissions were assessed in a pre-admission clinic Only 15 were reported to have had action taken as a result of the clinic visit

15. Health professional who assessed the patients

16. Pre-admission assessment Protocols for assessment and referral by the clinic need to be explicit Anaesthetists should be involved in the development of the assessment guidelines Findings of morbidity/mortality reviews should be considered when reviewing protocols

17. A 71-year-old female with no previous medical problems was admitted at 03.00 with an acute abdomen. At this time a HO assessed her and noted that she was shocked. The results of her serum biochemistry investigations were creatinine 471 micromol/l and a base excess of -11.8 mmol/l. At 07.40 she was reviewed by a surgical SHO who confirmed the admission findings. At 09.30 she was referred to a surgical registrar and consultant. At 11.30 she was reviewed by a consultant anaesthetist who agreed to take her to the ICU for resuscitation. A bed was available there at 14.00. Laparotomy started at 16.50. Delay once admitted

18. National protocols should be formulated to identify which inpatients would benefit from a more detailed preoperative cardiovascular assessment, including echocardiography Recommendation

19. When a formal preoperative medical assessment is indicated, an experienced physician, preferably a consultant, must make it. It is the responsibility of that physician to fully understand the operative risks of the patient’s medical condition Recommendation

20. Anticipated risk of death

21. Drug prescribing

22. Recommendation There need to be national guidelines for clinical prescribing in hospitals in order to reduce the risk of drug error

23. Monitoring

24. Should pulmonary artery pressure and cardiac output be measured more often? There were 18 cases where national guidelines for minimal monitoring were breached

25. Recommendation There are national agreed standards for anaesthetic monitoring. The absence of an essential anaesthetic monitor constitutes an unacceptable clinical risk that must be the subject of audit

26. FUNCTIONING AS A TEAM? The 2002 Report of the National Confidential Enquiry into Perioperative Deaths

27. Involvement of the consultant surgeon in decision making

28. Grade of most senior operating anaesthetist

29. Grade of most senior operating surgeon

30. Recommendation The decision to operate in complex cases can benefit from the formal involvement of others apart from the surgeon. Critical care specialists should be more directly involved

31. Decision-making & team working 77 year-old woman under the care of a physician with nausea, vomiting & constipation. Four days later - perforated viscus. Surgeon arranged laparotomy. SHO anaesthetist called consultant who asked for a second opinion. Surgeon declared that he was only a technician and could not make any decisions. Surgery done - Hartmann’s procedure for faecal peritonitis. Patient died in ICU several hours later.

32. Problems with diagnosis There were 12 deaths due to acute appendicitis The diagnosis needs skill and experience

33. Appendicitis 21 year-old man seen in A&E by SHO with abdominal pain & vomiting. Tachycardia, pyrexia, urine normal & high white cell count. Sent home as UTI. 5 days later readmitted moribund with peritonitis. Cardiac arrest. ICU. Laparotomy - gangrenous appendix & widespread peritonitis. Died 24 hours later.

34. Recommendation Failure to diagnose acute appendicitis can still cause death in fit young adults. It is essential that experienced clinicians are available to ensure that cases are not missed

35. Patients admitted under the care of physicians 79 year-old woman admitted under care of a physician with abdominal pain & vomiting. 4 days later an abdominal X-ray film showed intestinal obstruction. Operation for strangulated femoral hernia & small bowel resection. Transferred to HDU but died.

36. Preoperative preparation & timing of surgery Physicians need to raise their awareness of surgical conditions existing or developing inpatients under their care – Planning – Co-operation – Teamwork

37. Medical Records Patient admitted with abdominal pain & constipation. Had been previously investigated. Patient unclear about his condition. Notes & X-rays not available. 3 days later perforated colon & laparotomy done. Original x-rays still not available. In fact 2 weeks before, a barium enema & flexible sigmoidoscopy had diagnosed an obstructing carcinoma of colon.

38. Recommendation Non-availability of a patient’s previous notes at the time of an acute admission is a major administrative failure and should be exposed as such

39. FUNCTIONING AS A TEAM? The 2002 Report of the National Confidential Enquiry into Perioperative Deaths

40. Destination after surgery

41. Postoperative ward care Problems of – Poor record keeping – Hypotension – Oliguria

42. Postoperative ward care A 76-year-old ASA 3 female without recognised co-existing medical disorders had a mastectomy and axillary clearance. Three days later she was found 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 since mastectomy”. By this time the patient was in fast atrial fibrillation, dehydrated and in renal failure. Despite aggressive resuscitation she died later that day.

43. Postoperative ward care An 87-year-old female had a cholecystojejunostomy to relieve jaundice caused by a carcinoma of the head of the pancreas. She was otherwise fit. At 04.00 on the second postoperative night the urine output decreased, but this was not reported to the on-call doctor until 07.00, by which time it had been 4 ml/hour for two hours. No action was taken. The SpR ward round took place at 09.00, at which time the patient showed clear signs of hypovolaemic shock. Blood results showed a haemoglobin level of 3.7 gm/dl.

44. Postoperative ward care An 85-year-old man had a gastrectomy. He suffered from type II diabetes mellitus and mild angina. He was reviewed on the second postoperative day because of poor urine output and hypotension. Blood gas analysis revealed a P a O 2 of 5.2 kPa and a base excess of -7.6 mmol/l. He had a positive fluid balance since operation of 6 litres. He had a raised JVP, a pleural effusion, and his cardiac rhythm had changed to atrial fibrillation. The medical SpR thought that a cardiorespiratory cause for his deterioration was unlikely but that he might have suffered an intra-abdominal event. A laparotomy was performed later that day. No new pathology was found.

45. Recommendation If a medical team is involved in a patient’s perioperative care it should also be involved in any morbidity/mortality review of the case and receive a copy of the discharge summary and, where available, the autopsy report

46. FUNCTIONING AS A TEAM? The 2002 Report of the National Confidential Enquiry into Perioperative Deaths

47. Avoiding or diminishing postoperative complications Careful patient selection Preoperative preparation Anticipation Early recognition Some patients are too ill for anaesthesia & surgery

48. Unanticipated intraoperative complications

49. Recommendation Where perioperative complications contribute to the cause of death, these should be recorded on the death certificate

50. Recommendation Complications may arise following endoscopic surgery. Remedial actions should be rehearsed

51. Complications after endoscopic surgery 62 year-old woman. Laparoscopically assisted vaginal hysterectomy, sacral colpopexy & colposuspension for urinary incontinence & prolapse. Problems after surgery. Admitted 2 weeks later but discharged. Continued to be unwell. 2 months later readmitted & ureteric damage diagnosed. Died on table during corrective surgery.

52. Autopsy rate

53. Type of autopsy

54. Coroner’s autopsy rate following referral

55. The Autopsy Cases in which no autopsy was performed may not have been fully investigated

56. Lack of autopsy Fit 75 year-old man being treated for small recurrences of bladder tumour. Following day had massive haematemesis and died. Surgeon anticipated autopsy but Coroner’s officer refused and pressurised trainee surgical staff into writing a death certificate. Consultant surgeon complained but no autopsy done.

57. Some of the autopsies were unsatisfactory and did not explain the death. Problems included: – Brevity – Failure to examine operation site – Lack of clinicopathological correlation – Lack of histology The Autopsy

58. The Quality of the Autopsy Report (1)

59. The Quality of the Autopsy Report (2)

60. 2%10%Failure to explain death (poor autopsy) 2%5%Failure to explain death (good autopsy) 1%6%Major Discrepancy 72%75%Confirmation of clinical findings 1994/952000/01 Clinical diagnosis compared with autopsy findings

61. Receipt of autopsy report by clinical team

62. Problems with communication Surgeon: ‘Our coroner does not permit communication between his pathologist and the surgeon unless the surgeon has a specific question’

63. Problems with communication Surgeon: ‘I would like permission to forward a copy of the postmortem report on my patient to NCEPOD’ Coroner: ‘In my opinion NCEPOD is not an “interested party”. If they require a copy they need to apply directly to my office’

64. The clinicians perspective of the Autopsy The autopsy is a fundamental part of the on-going examination of clinical practice Coroners must understand their role in supporting this requirement

65. Communication Arrangements for communication between clinicians and pathologist should be formalised Clinicians should provide a case summary, including contact details for further discussion Pathologists and clinicians should hold multidisciplinary audit meetings

66. Recommendation Autopsies should be the subject of a formal external audit process. Clinicians should be involved in evaluating the quality of reports and the basis of conclusions drawn, including the cause of death

67. FUNCTIONING AS A TEAM? The 2002 Report of the National Confidential Enquiry into Perioperative Deaths

68. Issues for consideration Increased remit Name Data collection methods Case control Feedback Dissemination of findings & recommendations

69. Future studies Who Operates When II? - Publ. Nov 2003 Gastrointestinal Endoscopy - Publ. 2004 Critical Care & the Medical Patient - Publ. 2004 Emergency admissions - Publ. 2005 Ruptured AAAs - Publ. 2005

70. FUNCTIONING AS A TEAM? The 2002 Report of the National Confidential Enquiry into Perioperative Deaths