Abstract:
In November 2008, the United Kingdom National Confidential Enquiry into Patient Outcome
and Death (NCEPOD) published an inquiry into deaths within 30 days of systemic anti-cancer
therapy (SACT). This study aims to replicate the national enquiry on a hospital level and perform root
cause analysis of any identifiable causes of death. The main objective of this study is to conduct a
systematic case-by-case enquiry into deaths fulfilling study criteria to ascertain any remediable
factors present in each death, reflecting the rigorous methodology of the national study. Also, another
objective is to ensure there were no compromises in the quality of clinical care or organisational
policy and to suggest relevant changes in practice. The inclusion criteria were all patients who had
identifiably died within 30 days of SACT in James Cook University Hospital in 2009. Information
was gathered from patient case notes and the minutes of the 2009 hospital mortality meetings. 5 areas
of clinical care, namely decision to treat, prescriptions and administrations, safety, hospital
admissions during last 30 days of life and palliative care were investigated. Results 12 deaths were
deemed eligible for inclusion. Of these only 6 died of causes directly related to malignancy. Half the
deaths were in patients with performance status above 3 (bedridden >50% daily) at time of decision
of final SACT, reflecting national concerns about overly infirm patients receiving inappropriate
SACT. Also flagged up were alarmingly infrequent SACT discussions at multidisciplinary meetings
(2/ 12) and non-consideration of dose reductions in patients with serious comorbidities, mirroring poor
practise at national level. Among other minor treatment issues, crucially, prophylactic granulocytecolony stimulating factor (G-CSF) in patients who had previously suffered SACT toxicity was rarely
considered. Evidently findings of poor practice at national level are echoed at hospital level,
confirming the reproducibility of the NCEPOD inquiry. Existing hospital-level policies that would
avert many abovementioned failures in clinical practice were not rigidly adhered to. This implies
unnecessary deaths are possibly occurring. In conclusion, despite relatively small patient numbers
dying within 30 days of SACT, there are still avoidable sources of clinical error that may compromise
haematological standards of care.
