The following links will take you to the relevant pages of the NCEPOD website, where you can view and save the reports. (Report descriptions by NCEPOD).

Deaths in Acute Hospitals: Caring to the End? (2009)
This NCEPOD report highlights the process of care of patients who died in acute hospitals within four days of admission. It takes a critical look at areas where the care of patients might have been improved. Remediable factors have been identified in the clinical and the organisational care of these patients.

Acute Kidney Injury: Adding Insult to Injury (2009)
This NCEPOD report highlights the process of care of patients who died in hospital with a primary diagnosis of acute kidney injury (AKI). It takes a critical look at areas where the care of patients might have been improved. Remediable factors have been identified in the clinical and the organisational care of these patients.

Systemic Anti-Cancer Therapy: For better, for worse? (2008)
This NCEPOD report highlights the process of care of patients who died within 30 days of receiving systemic anti-cancer therapy (SACT). It takes a critical look at areas where the care of patients might have been improved. Remediable factors have been identified in the clinical and the organisational care of these patients.

Coronary Artery Bypass Grafts: The heart of the matter (2008)
This NCEPOD report analyses the care of a sample of patients who in the majority did not survive to leave hospital following their CABG operation. It takes a critical look at the selection of the surgery and the strategy and the organisational factors involved in its implementation.

Sickle: A sickle crisis? (2008)
NCEPOD was pleased to undertake a review of current haemoglobinopathy mortality, to obtain broad baseline data and make recommendations to alter practice. In this way, we hope to contribute to improving the quality of life of patients – whose numbers and attendances at health care centres are inevitably going to increase.

Trauma: Who Cares? (2007)
This study shows a rounded picture of current trauma care provision in England, Wales, Northern Ireland and the Offshore Islands. It draws on data provided by the clinicians involved in the are of these patients (from questionnaires) and data extracted from the casenotes. However, these data are accompanied by peer review, by practising clinicians involved in the day-to-day care of trauma patients, to give a much richer picture than a purely quantitative assessment would allow.

Emergency Admissions: A jouney in the right direction? (2007)
In this study, NCEPOD has assessed organisational and clinical aspects of both the immediate and ongoing care of patients admitted as emergencies. The report highlights remediable factors in existing care pathways, particularly the appropriateness, timeliness and frequency of investigations and reviews, the experience of staff and the availability of results, protocols and procedures.

The Coroner’s Autopsy: Do we deserve better? (2006)
Following a proposal from the Royal College of Pathologists, NCEPOD has reviewed, in detail, the autopsy reports produced for the coroners; this includes both deaths in hospitals and in the community.

Abdominal Aortic Aneurysm: A service in need of surgery? (2005)
Abdominal aortic aneurysm is a life threatening condition and once a decision has been made to operate, this should be carried out as expeditiously as possible. In patients scheduled for elective major vascular surgery, numerous factors contribute to delays, not least of which is the availability of high dependency and intensive care facilities.

An Acute Problem?(2005)
“An Acute Problem?” is the second study related to our enlarged responsibility for including medical cases. It has been designed to link together the provision of critical care facilities with the care of severely ill medical patients throughout our hospitals. The pattern of inpatient care is changing rapidly and NCEPOD’s role is to facilitate and inform that change. This study is as much about facilities and resources as about clinical practice and highlights the levels of care appropriate to patient requirements.

Scoping our practice (2004)
Although GI endoscopy as a specialty has produced good guidelines on training, the report highlights the need for national guidelines to assure continuing competence in endoscopy, particularly for those practitioners who only perform a small number of procedures each year. If we are to significantly improve the outcome of patients undergoing therapeutic endoscopy this report gives us many clear indications and recommendations about how this might be achieved.

Who Operates When? II (2003)
The first ‘Who Operates When?’ (WOW I) report was published in 1997 and considerable changes have occurred in the staffing and surgical activity of hospitals since that time. This report again reinforces the need for sufficiently robust information and data collection systems in every Trust. Although this is often believed to be primarily necessary for producing accurate activity data, it is becoming increasingly important in clinical governance, risk management and other indices of morbidity and mortality.

Functioning as a Team? (2002)
National CEPOD has repeatedly emphasised the need for the development of multi-professional and multidisciplinary teams to provide optimum care for the most seriously ill patients. In this report, based on deaths within three days of an intervention, NCEPOD looks at how far team working has developed and, most particularly, at weaknesses in the systems which create barriers to change.

Changing the Way we Operate (2001)
This report provides a stark comparison of the changing medical scene over the past decade. It demonstrates that patients being subjected to emergency surgery are both older and sicker than they were ten years ago. In turn, this has a profound impact on the service provision necessary to deal with these clinical problems.

Then & Now (2000)
The Department of Health report on learning from adverse events, ‘An Organisation with a Memory’, commented upon the serious difficulty in establishing the rate of change when good practice recommendations are made by National Confidential Enquiries. This report, therefore, covering a period of almost ten years enables us to evaluate some of the changes that have occurred, but possibly more particularly to highlight the issues where changes have been less than adequate and certainly the rate of change has been unacceptably slow.

Percutaneous Transluminal Coronary Angioplasty (2000)
This is a small survey by NCEPOD standards, but one of great importance, and demonstrates the value of the acquisition of reliable data by clinicians involved, and the importance of recording this on a national level to assess the quality of outcomes.

Interventional vascular radiology and interventional neurovascular radiology (2000)
Significant advances in interventional techniques, particularly in vascular and neurovascular radiology, in the last decade have led NCEPOD to explore the morbidity and mortality associated with such procedures. In view of the frequency with which these minimally invasive techniques are being carried out, it is important that the consequences of such interventions should be investigated.

Extremes of Age (1999)
This report concentrates on the extremes of age. In detail there are obvious differences between the groups, yet many of the lessons to be drawn from this study span the age difference.

The 1996/7 Report of NCEPOD
In this report recommendations were made with reference to specific surgical procedures: gynaecological surgery; head and neck surgery; minimally invasive surgery; oesophageal surgery; spinal surgery; urological surgery.

The 1995/6 Report of NCEPOD – Who Operates When?
This original report reviewed all surgical procedures during a one week period to identify the grades of surgeons operating and when the surgery was performed. This report led to the introduction of ‘CEPOD’ theatres.

The 1994/5 Report of NCEPOD
This report focussed on the first perioperative death, within three days of surgery, reported for each surgeon or gynaecologist.

The 1993/4 Report of NCEPOD
This report focussed on the first perioperative death reported for each surgeon or gynaecologist.

The 1992/3 Report of NCEPOD
This report was similar to the 1991/1992 report but looked at a sample of perioperative deaths in people aged 6 to 70 years.

The 1991/2 Report of NCEPOD
This report covered the largest sample to date. The study included all perioperative deaths of patients aged 6 to 70 years.

The 1990 Report of NCEPOD
This report provided results on the review of a random 20% sample of patients over the age of 10 who died perioperatively.

The 1989 Report of NCEPOD
The 1989 report of the National Confidential Enquiry into Perioperative Deaths highlighted the standard of surgical and anaesthetic care received by children.

The 1987 Report of NCEPOD
The first report of the National Confidential Enquiry into Perioperative Deaths highlighted the standard of surgical and anaesthetic care received by patients.