Shorter doctors' hours lead to more deaths, says study

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Serious lapses in the care of patients including missed diagnoses, drug errors and a lack of intensive care are identified in a report today into 20,000 deaths after surgery.

Serious lapses in the care of patients including missed diagnoses, drug errors and a lack of intensive care are identified in a report today into 20,000 deaths after surgery.

Modern ways of working, with shorter hours and shift systems, mean that individual doctors are becoming "transient acquaintances" of patients during their passage through an illness, undermining continuity of care and contributing to unnecessary deaths.

The annual review of deaths after surgery in 2000-01 says poor communication among medical staff and lack of resources are key problems facing the health service. It estimates 400 patients who died were denied an intensive care bed and 59 intensive care units had no specialist cover on at least one day a week.

It also blames "short-term political incentives" concerned with cutting waiting lists for distorting clinical priorities. The review is the 14th by the National Confidential Inquiry into Perioperative Deaths (within 30 days of an operation) set up to monitor standards of surgery. It is based on reports of a sample of deaths that followed the six million operations in hospitals annually and this year includes detailed analysis of 7,000 deaths within three days of surgery.

In some cases, elementary diagnoses were missed. There were 12 deaths from appendicitis, two of them in fit young men. One of these, a 21-year-old man, attended his local accident and emergency department complaining of abdominal pain and vomiting. After examination by a junior doctor, who thought he had a urinary tract infection, he was sent home.

Five days later he returned and collapsed in the A&E department with a heart attack. He was resuscitated and operated on, whereupon surgeons found a gangrenous appendix and widespread peritonitis. They were unable to save him.

The report describes the cases as "alarming" and says experienced clinicians must be available "to ensure that cases are not missed". It adds that 70 per cent of patients who died after surgery were emergency admissions and frequently they had other medical problems that were missed.

The report says that once patients are admitted, uncertainty over where responsibility for the patient's care lies is being caused by the cut in doctors' hours, to bring them into line with the European working time directive. "There appears to be an emerging picture of poor ward care by medical staff ... Currently the only constant factor is the consultant who is now subject to increasing and conflicting pressure ... There has to be more working as a team."

Ron Hoile, joint author of the report and a general surgeon at Medway NHS Trust, said doctors had to learn from nurses how to hand over care at the end of a shift. "We have to work out how information is exchanged. At the minute that is not being addressed. Nurses have a very formal handover. That doesn't happen in medicine," he said.

In the case of 18 deaths, key pieces of anaesthetic monitoring equipment were missing, in contravention of the Association of Anaesthetists' recommendations. The report says this is an "unacceptable clinical risk".

In a veiled criticism of government policy it asks: "Will these pieces ever link together whilst current inadequate staffing levels, restraints on working hours and short-term political incentives ... are allowed to predominate?"

It suggests there should be two systems, separating emergency and routine care.

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