The National Confidential Enquiry into Patient Outcome and Death (NCEPOD) (2009) reviewed the care of patients who died in hospital within four days of admission.
They found in 25 per cent of cases there was a 'clinically important delay in the first review by a consultant', and poor communication between and within clinical teams was identified by advisors as 'an important issue in 13.5 per cent of cases'.
John Black, president of the Royal College of Surgeons has said the importance of today's report must be recognised: 'This hard hitting report highlights the loss of proper team working in UK hospitals, resulting in dangerous failures of communication which make it harder and harder for clinicians to provide safe care for patients.
'The Royal college of Surgeons has been warning for some time about the dangers of multiple handovers.'
The report found there was a lack of communication both between different grades of doctors within clinical teams, and between different clinical teams and other health care professionals.
Poor-decision making and lack of senior input were also issues, as was the access to CT and MRI scanning. In 16.9 per cent of patients who were not expected to survive on admission there was no evidence of any discussion between the health care team and either the patient or relatives on treatment limitation.
Mr Black added: 'The problems revealed in this report date from 2006 and 2007, when the NHS was already struggling to meet the demands of a 56 hour working week. Now that in theory everyone in the NHS is working for only 48 hours the situation in the country's hospitals can only have worsened.'
The report also said the NHS needed to look at the lack of involvement of trainees in emergency surgery in a supervised learning environment, adding that there was a poor standard of record keeping and some of the basic aspects of clinical care continue to be neglected; in particular the monitoring, recording and management of fluid balance in the elderly and those with multiple comorbidities.
They found in 25 per cent of cases there was a 'clinically important delay in the first review by a consultant', and poor communication between and within clinical teams was identified by advisors as 'an important issue in 13.5 per cent of cases'.
John Black, president of the Royal College of Surgeons has said the importance of today's report must be recognised: 'This hard hitting report highlights the loss of proper team working in UK hospitals, resulting in dangerous failures of communication which make it harder and harder for clinicians to provide safe care for patients.
'The Royal college of Surgeons has been warning for some time about the dangers of multiple handovers.'
The report found there was a lack of communication both between different grades of doctors within clinical teams, and between different clinical teams and other health care professionals.
Poor-decision making and lack of senior input were also issues, as was the access to CT and MRI scanning. In 16.9 per cent of patients who were not expected to survive on admission there was no evidence of any discussion between the health care team and either the patient or relatives on treatment limitation.
Mr Black added: 'The problems revealed in this report date from 2006 and 2007, when the NHS was already struggling to meet the demands of a 56 hour working week. Now that in theory everyone in the NHS is working for only 48 hours the situation in the country's hospitals can only have worsened.'
The report also said the NHS needed to look at the lack of involvement of trainees in emergency surgery in a supervised learning environment, adding that there was a poor standard of record keeping and some of the basic aspects of clinical care continue to be neglected; in particular the monitoring, recording and management of fluid balance in the elderly and those with multiple comorbidities.
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