Patient care is being compromised, say the report authors
Poor communication between hospital staff and with their patients is far too common and deeply damaging, experts have warned.
Patients left out of the loop and staff clocking on and off without a handover was commonplace, according to the findings of a confidential review.
The National Confidential Enquiry into Patient Outcome and Death looked at the care of over 3,000 terminal patients.
It revealed two-fifths received "sub-standard" care.
Change in the hospital team structure over recent years has seen individual clinicians become "transient acquaintances during a patient's illness rather than having responsibility for continuity of care", says the NCEPOD report.
Kept in the dark
It found a co-ordinated handover of patients between night and day staff only occurred in a quarter of the teams.
In 13.5% of cases lack of communication compromised continuity of patient care.
In just over half (53%) of cases there was an apparent lack of input from senior doctors "leading to delays in giving patients timely and appropriate care", report author and surgeon Ian Martin said.
And 30% of the patients were not seen by a consultant within the recommended 12 hours after admission.
In a fifth of patients who were not expected to survive on admission there was no evidence of any discussion between the health care team and either the patient or relatives on treatment limitation.
Many "do not attempt resuscitation" orders were signed by very junior trainee doctors.
NCEPOD chairman Professor Tom Treasure said the report vividly revealed the challenge medical teams face in making the transition between saving life and allowing natural death.
"It should be ensured that patients achieve the best quality of life until they die. Effective team working and communication with patients, relatives and carers are fundamental to getting this right."
Director of the Patients Association, Katherine Murphy, said: "These findings run the risk of undermining basic confidence in the NHS. Some of the examples are shocking.
"NCEPOD is the nearest the NHS has to airline 'near miss reporting'. Its findings must be acted upon, or problems will continue to plague vulnerable patients and their families."
Working time directive
John Black, president of the Royal College of Surgeons, said doctors had long been concerned that the loss of team working in hospitals had fuelled the risk of poor communication, and sub-standard patient care.
He said the implementation of a 48-hour working week under the European Working Time Directive almost certainly meant that the problem had got worse since the latest study was carried out.
Professor Black said the only way to address the problem was to opt out of the directive.
A Department of Health spokesperson said measures had been introduced to improve care - including an end of life strategy - since the report's survey was carried out.
"We are putting in place an extensive programme of health and social care training to support end of life care provision, including pilot projects to support the development of communication skills.
He added that evidence from hospitals already implementing a 48-hour week showed a drop in mortality and no evidence of harm to patients.
"Working together with the local NHS and the Royal Colleges we have set up a rigorous quality assurance process to give us an accurate picture of how EWTD is being implemented and so we can provide support where it is needed."