NCEPOD have issued strong recommendations, including calls for further national guidelines, to improve the management, optimization, treatment and sedation of what are often seriously ill, elderly patients.
The report, 'Scoping our practice'carried out in Britain examines in detail 1,818 inpatient deaths within 30 days of the procedure.
This sample of patients represented just under 50% of all deaths in this category and these are only a small proportion (3%) of the total endoscopies performed during a year in England, Wales and Northern Ireland (136,000 in 2002/2003).
NCEPOD found that the procedure performed in 14% of cases was inappropriate and of these more than half were deemed 'futile'.
In 14% of cases, patients were judged to have received an overdose of sedation, and monitoring of the patient in 23% of cases was judged to be deficient.
NCEPOD also found that 62% of hospitals do not operate a dedicated out of hours rota for emergency cases.
| In 19% of people who died, NCEPOD advisors considered the procedure futile|
Only 47% had ECG monitoring in every room, and 37% had no ECG monitors in the endoscopy unit at all.
NCEPOD recommended that hospitals should ensure that appropriate monitoring and resuscitation equipment is available in each of their endoscopy rooms and recovery areas.
In addition, hospitals should consider establishing formal on-call arrangements.
NCEPOD advisers expressed disquiet over the extent and quality of information that some patients may have received before entering the endoscopy room.
The investigators found that 2/3 patients who had dementia or acute confusion provided written consent.
NCEPOD recommended that the risks and benefits of therapeutic endoscopy be explained to the patient.
Consultants performed 3/4 of procedures in this study. However, some only performed a few procedures per year, often less than 20.
Dr Anthony Gray, lead clinical coordinator for NCEPOD said, "There are detailed guidelines on the numbers of procedures required to establish initial competence, but nothing on how many endoscopies doctors need to perform each year to maintain competence".