Are We There Yet? A review of organisational and clinical aspects of children’s surgery

Are We There Yet? A review of organisational and clinical aspects of children’s surgery A report by the National Confidential Enquiry into Patient Outcome and Death (2011) Written by: D G Mason MBBS FFARCS NCEPOD Clinical Co-ordinator (Anaesthetics) Oxford Radcliffe Hospitals NHS Trust K Wilkinson FRCA FRCPCH NCEPOD Clinical Co-ordinator (Anaesthetics) Norfolk and Norwich University Hospitals NHS Foundation Trust M J Gough ChM FRCS NCEPOD Clinical Co-ordinator (Surgery) The Leeds Teaching Hospitals NHS Trust S B Lucas FRCP FRCPath NCEPOD Clinical Co-ordinator (Pathology) Guy’s and St Thomas’ NHS Foundation Trust H Freeth BSc (Hons) MSc RGN MSc - Clinical Researcher H Shotton PhD - Researcher M Mason PhD - Chief Executive The authors and Trustees of NCEPOD would particularly like to thank the NCEPOD staff for their work in collecting and analysing the data for this study: Robert Alleway, Aysha Butt, Donna Ellis, Kathryn Kelly, Dolores Jarman, Sherin Joy, Waqaar Majid, Sabah Mayet, Eva Nwosu, Karen Protopapa, and Neil Smith. Special thanks are given to Professor Martin Utley from the Clinical Operational Research Unit at University College London, for his scientific advice.

Contents Acknowledgements 3 Foreword 5 Principal recommendations 7 Introduction 9 Chapter 1 – Method and data returns 11 Chapter 2 – Organisational data 15 Key findings 41 Recommendations 42 Chapter 3 – Peer review data 45 Key findings 69 Recommendations 70 Chapter 4 – Specific care reviews 73 Key findings and Recommendations 85 Chapter 5 – Autopsy and pathology 87 References 89 Appendices Appendix 1 - Glossary Appendix 2 - Role and structure of NCEPOD Appendix 3 - Hospital participation Data available on NCEPOD’s website Appendix 4 - OPCS codes of excluded cases

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This report, published by NCEPOD, could not have been achieved without the support of a wide range of individuals who have contributed to this study. Our particular thanks go to: The Expert Group who advised NCEPOD on what to assess during this study: Bob Bingham Bill Brawn Sarah Cheslyn-Curtis Ian Doughty Leslie Hamilton Gale Pearson Ann Seymour Jo Smith Roly Squire Jim Wardrope

Consultant paediatric anaesthetist (cardiac) Consultant paediatric cardiac surgeon Consultant general surgeon with an interest in paediatric surgery Consultant paediatrician Consultant cardiac surgeon Consultant paediatric intensivist Lay representative Lecturer in children and young people’s nursing Consultant paediatric general surgeon Consultant in accident and emergency medicine

The Advisors who peer reviewed the cases: David Anderson Conal Austin Martin Bailey Ian Barker Nigel Barker Kathleen Berry Christopher Bradish Liam Brennan Josie Brown Pam Cairns Sandy Calvert Philip Chetcuti Peter Crean Mary Cunliffe Mark Darowski Marc Davison Perry Elliott Mark Farrar Scott Fergusson Dorothie Garvie Andrew George Elizabeth Gormley-Fleming

Consultant paediatric cardiac surgeon Consultant paediatric and adult cardiothoracic surgeon Consultant otolaryngologist Consultant paediatric anaesthetist Consultant paediatric anaesthetist Consultant paediatrician Consultant paediatric orthopaedic surgeon Consultant paediatric anaesthetist Consultant paediatric anaesthetist Neonatologist Neonatologist Consultant paediatrician with a neonatal interest Consultant paediatric anaesthetist Consultant paediatric anaesthetist Consultant paediatric intensivist Consultant anaesthetist Cardiologist Consultant paediatric anaesthetist Consultant paediatric anaesthetist and intensivist Consultant neonatologist Consultant anaesthetist Paediatric nurse

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Acknowledgements

s w ledgement k no ac Emma Gray Rodney Hallan Kath Halliday Susan Hartley Alison Hayes Simon Huddart Ian James Simon Kenny Dorothy Kufeji Peter MacFarlane Alan Magee Rebecca Mawer Paddy McCleary Angus McEwan John Meyrick Tho