Some of the sickest patients that hospitals treat are dying unnecessarily because they receive poor care, blighted by shortages of staff and equipment, a new NHS inquiry has revealed.
A death rate of one in three among inpatients who need emergency help with breathing is already high by international standards, and is getting worse.
The analysis by the National Confidential Enquiry into Patient Outcome and Death of NHS services for the 50,000 patients a year who receive emergency oxygen treatment uncovered a series of major flaws in the care they received. It described its findings as “shocking”.
The growing numbers of patients who receive non-invasive intervention (NIV) – oxygen through a face mask – usually have chronic obstructive pulmonary disease, pneumonia or other conditions which mean they cannot breathe unaided. Despite their lives being at risk, the vast majority receive sub-standard care, according to an in-depth examination of 353 patients during February and March.
“The care of these patients was rated as less than good in four out of five cases. The mortality rate was high: more than one in three patients died,” the inquiry found. “Supervision of care and patient monitoring were commonly inadequate. Case selection for NIV was often inappropriate and treatment was frequently delayed due to a combination of service organisation and a failure to recognise that NIV was needed.” In addition, investigators found from examining case notes that “the quality of medical care provided was often poor. This poor care included both non-ventilator treatment and ventilation management, which were frequently inappropriate”.
Dr Mark Juniper, a co-author of the report and NCEPOD’s lead clinical coordinator for medicine, said the sheer extent of problems he and his colleagues uncovered meant their hard-hitting conclusions were justified.
“This is a major problem which is resulting in unnecessary loss of life. Four out of five patients didn’t receive care that we as doctors would be happy to receive. That’s quite an indictment. That’s shocking because all these patients are at risk of dying.”
NIV in emergency situations is meant to reduce the risk of dying from 20% to 10%. However, NCEPOD found that the death rate among UK patients is 34% – “really troubling”, said Juniper. By contrast, it is only 18% in Spain while France has cut its death rate in recent years from more than 20% to 10%. The UK death rate has been rising steadily since the 30% recorded in 2011.
Two out of five hospitals at some point had been unable to cope with the number of patients who needed NIV because they lacked equipment. “Lack of ventilators is a common problem, even though a basic machine costs about £1,000 to £2,000. When there are too many patients, some end up receiving other medical treatment that’s not as good as ventilation. That will give them a higher risk of dying.”
Other failings researchers found included a lack of nurses, meaning that less than half of hospitals are able to provide the staffing ratio – one nurse to two NIV patients – which guidelines since 2010 have said should be in place. One in five patients who received NIV either did not need it, or needed to be on life support in an intensive care unit instead. In 47% of cases doctors did not convert the patient’s vital signs, such as their temperature, blood pressure and oxygen levels, into an “early warning score” to help dictate the treatment they received. Doctors were often “really poor” at documenting the condition of patients on NIV, probably because of understaffing.
“With these very sick patients the NHS needs to improve a lot – and fast, because lives are at stake,” said Juniper.
Dr Mike Davies, a consultant in respiratory medicine and spokesman for the British Thoracic Society, which represents lung specialists, said the findings had to “act as a stimulus to improve care for NIV patients. We need a concerted effort across the NHS to help reduce avoidable deaths.”
Professor Lesley Regan, who chairs NCEPOD, said the NHS had to learn lessons from the inquiry, given how many patients receive inadequate care. “Many hospitals fail to grasp the size of the problem, as acute NIV usage is all too easily hidden due to poor coding.”
NCEPOD has also found inaccurate coding causes problems among patients who have had a tracheostomy or have sepsis or acute pancreatitis.
She wants hospitals to appoint “local champions” to assess the state of NIV services and ensure that they have the staff and equipment needed.