Parenteral nutrition (PN) is an important and widely used component in the care of neonates and children when gastrointestinal immaturity or disease precludes nutritional needs being met via the enteral route. The process of providing PN is complex, technically demanding, requires skill and judgement, and is fraught with the risk of complications. The National Confidential Enquiry into Patient Outcome and Death (NCEPOD), an independent charity, has recently completed a case-based observational peer review of PN clinical practice in England, Wales and Northern Ireland—the first large-scale review of this type conducted in the UK.1 Based on the findings of the studies undertaken, NCEPOD makes recommendations to clinicians and management aimed at improving the quality of patient care. While undoubtedly this current report identifies evidence of good clinical practice it also highlights deficiencies that need careful evaluation by the healthcare community.

Patients of all ages who received PN between 1 January and 31 March 2008 were identified from local pharmacy records in hospitals in England, Wales and Northern Ireland and Offshore Islands. A random selection of these cases was chosen for inclusion using Access (Microsoft, Redmond, Washington). For each patient a confidential questionnaire was sent to the consultant in charge with a limit of two cases per consultant. The questionnaire was returned to NCEPOD with copied extracts of the case notes. The case notes were anonymised and peer-reviewed by a multidisciplinary group of advisors. For neonates and children, this group comprised neonatologists, gastroenterologists, dietitians, nutrition nurses and clinical pharmacists.

A total of 1211 cases were reviewed: 877 adults, 70 children and 264 neonates. Much of the report focuses on PN in neonatal practice. Overall ‘good practice’ in PN care, defined for the Advisors as a ‘standard that you would accept from yourself, your trainees and your institution,’ was identified in only …