Craig Gannon, a consultant in palliative medicine, describes the fragmented care of an elderly woman at his hospital whose death from kidney failure (super-imposed on a malignancy) could have been avoided.
"The hospital care was spread across three sites, delivered by six teams and by numerous members of within each team, while the information passed to her GP was patchy," he writes.
"Worryingly, it was the system - increasingly engineered to medical technicians rather than to professionals - that seemed to be responsible," he says. "The presiding tick box culture allowed and even fostered suboptimal assessment."
Although individual clinicians did what they were asked, they did no more than what was required. Biases towards qualitative measures (which are used to guard against litigation) can neglect the quality of care, he argues.
"We need to revitalise the role of the lead clinician," he writes. "Clearer ownership of patients should minimise oversights generated by ever expanding teams and should improve continuity of care.
Healthcare systems must minimise errors and should require an approach that is as evidence based as our approach to prescribing," he concludes.
"How many such stories lurk in the corridors of today's NHS, and what do they tell us?" asks Fiona Godlee, BMJ Editor. "If this is, as Gannon implies, a result of recent reforms, what can we expect from the next phase of the government's NHS improvement plan unveiled by Nigel Crisp last week?"