Poor communication ‘compromising care’

Poor communication in hospitals within healthcare teams and with patients and their carers is a serious and recurring problem that is compromising the care of patients, particularly people nearing the end of their life, according to a survey from the National Confidential Enquiry into Patient Outcome and Death (NCEPOD). Deaths in Acute Hospitals: Caring to the End? reviewed the care of over 3,000 patients of all ages who died within four days of admission to hospital. According to the report, over 60% received good medical care but a third of patients did not. The reviewers found that half of the patients in the survey were not expected to survive, and also found evidence that healthcare professionals fail to make the judgement that patients are approaching the end of their life. This means that they fail to implement appropriate end of life care,” report author, Dr David Mason, pointed out. The report found that, following the admission of patients in an emergency or urgent setting, there is often no formal assessment of co-morbidities. Many, otherwise remediable, medical conditions go uncorrected, problems are overlooked, surgical complication rates are high and deaths occur despite the best anaesthetic, surgical and medical expertise available. The authors pointed out that much can be done to pre-empt such problems but this requires good planning and service, as well as a team that functions in a coordinated manner. They emphasised that continuity of care and an understanding of the case throughout the patient’s hospital stay must be assured. According to NCEPOD, change in the hospital team structure over recent years has seen individual clinicians become “transient acquaintances during a patient’s illness” rather than having responsibility for continuity of care. In its opening statement, the enquiry team was particularly critical of staffing arrangements and shift working, which it described as “disruptive” and predicted that, with the implementation of the European Working Time Directive, this disruption is likely to continue and to impact on the training of tomorrow’s doctors. Advisors undertaking the peer review of cases identified a number of recurring themes:

• Poor communication and team working.
 • Lack of multidisciplinary care.
• Poor end of life care planning.
• Lack of involvement of palliative care teams.
• Inadequate consent.
• Deficiencies in diagnosis.
 • Delay in assessment and treatment.
• Poor fluid and electrolyte management.
• Failure to recognise or manage malnourishment.
• Poor documentation.
• Failure to adapt level of care to health status of the patient.
• Failure of audit and critical incident reporting.
• Neglect of deep vein thrombosis and antibiotic prophylaxis.

Some of the report’s main findings are outlined below.