The objective of this column is to highlight several sources on good communication strategies, high-quality record keeping and so on. As well as informing readers' individual practice, I hope this will help those tasked with producing study days on the topic. I have tried to select a broad range of publications that present interesting and authoritative perspectives on the vexed issue of poor record keeping communication strategies – one that has plagued the NHS for years.
When you look back at the reports of adverse healthcare events, formal complaints and litigation, failures in communication seem to underpin many of them. If we improve our channels of communication there would undoubtedly be fewer complaints and less litigation. Poor communication strategies, including poor documentation, seems an easy acute patient safety issue to fix. There do not seem to be any major obstacles looming to stop improvement. In terms of fostering improvements, good record keeping and communication strategies should be seen much more as an intrinsic part of a nurse or doctors' individual professional skill set and duty. We should not be blandly accepting poor handwriting as a professional fact of life, as is seemingly the case in some quarters. If we confuse a number or figure it could mean that the wrong dose of a drug is given to a patient, with perhaps fatal consequences.
Despite the obviousness of the need to improve our communication practices and the dire consequences that can result from failure, patient safety reports and court cases still show these types of events happening on a regular basis.
Never Events in the NHS
Never Event data show the issues of poor NHS communication strategies in a tragic light. Many of these terrible events would not have happened had good communication strategies been in place. NHS England (2023) states that there were 262 serious incidents that appeared to meet the official definition of a Never Event and had an incident date between 1 April and 30 November 2022. This number is subject to change as local investigations are completed.
There were 122 wrong site surgery Never Events, which included:
- One gastroscopy intended for another patient
- Three lumbar punctures intended for another patient
- Two midline insertions intended for another patient
- One perineal biopsy intended for another patient
- One case of removal of both ovaries when surgical plan was to remove one of them
- Two cases of removal of ovaries when surgical plan was to conserve them
- One wrong eye procedure.
There were 63 retained foreign object post procedure Never Events, which included guidewires, surgical forceps and part of a drill bit not identified as missing at the time of the procedure. There were 27 wrong implant/prosthesis Never Events, which included five hip replacements, eight lens devices and one intrauterine contraceptive device intended for another patient.
Looking at feeding tubes, there were 20 misplaced nasogastric or orogastric tubes and feed administered Never Events, which included five cases where placement checks were not described or not clearly described. Finally, there were five Never Events relating to transfusion or transplantation of ABO-incompatible blood components or organs, which included four cases of the wrong blood being transfused.
The report also identifies the care providers where Never Events incidents have taken place; one trust is recorded as having nine Never Events and another eight during the reporting period. Communication failings must underpin these Never Events. Good record keeping and communication practices would identify the correct patient for a procedure and correctly identify the nature of the surgery to be carried out. With the list of Never Events we can see examples of record keeping, documentation and communication practices in the NHS at its very worst.
Maternity care
Keeping with the theme of recent reports showing communication failures, the Care Quality Commission (CQC) survey of maternity care shows that nationally women's experiences of maternity care have deteriorated in the past 5 years (CQC, 2023). Some of the failings specifically relate to communication failings, particularly interactions with staff.
‘The proportion of women and other pregnant people saying they were given appropriate advice and support when they contacted a midwife or hospital at the start of their labour, decreased from 87% in 2017 to 82% in 2022. 59% of women and other pregnant people were always given the information and explanations they needed during their care in hospital, down from 66% in 2017.’
In terms of raising concerns and feeling that these were being taken seriously during labour and birth the report notes a downward trend since 2017 from 81% to 77% in 2022.
History has not served NHS maternity services well with several reports addressing this problem. The two Kirkup reports (2015; 2022) are among those that have highlighted communication failings and their impact:
‘We have found a worrying recurring tendency among midwives and doctors to disregard the views of women and other family members. In fact, in a significant number of cases, the Panel has found compelling evidence that women and their partners were simply not listened to when they expressed concern about their treatment in the days and hours leading up to the birth of their babies, when they questioned their care, and when they challenged the decisions that were made. Too often, their well-founded concerns were dismissed or ignored altogether.’
Asking health professionals to exercise common decency and compassion and to talk to patients properly would not seem to be a very big ask. It is a basic tenet of being professional that we talk to our clients properly. This should go without saying, yet it is a recurring problem that I have seen in publications over the years:
‘In fact, in a majority of cases, families described aspects of their care that they felt were the result of unkindness and a lack of compassion and empathy.’
There are other maternity investigations in process, and I fear they may have similar findings (Harby and Cowley, 2022). The NHS is poor at learning the patient safety lessons of the past and many failings relate to basic communication processes.
Advice on record keeping
The Medical Defence Union (2021) offers advice on effective record keeping. There is a discussion of the purpose of records, what to include and how to record a consultation. In terms of maintaining the integrity of records notes should, the advice states, be complete, contemporaneous, clear, and legible, and entered for the correct patient. Ambiguous abbreviations should not be included, jokey comments avoided, notes should not be tampered with, and notes should be checked.
Hassan and Ford (2019), writing for Capsticks solicitors, offered advice in this area and discussed clinical negligence claims with some past court cases:
‘Medical records are the evidential starting point in a clinical negligence claim. A clinician's first and last impression is likely to be made through the records he has made. Judges tend to equate carefully made records with careful practice. If there is any doubt about the care or treatment provided a judge is likely to resolve an issue in favour of a witness with corroborating evidence or discount oral evidence when not supported by a clinical record.’
As a witness you are as good as your records on the day of a court hearing. As Hassan and Ford highlighted, the judge may well take the view that if something was never written then it never happened. It is hard to defend a nurse, doctor, or Trust if records are missing, incomplete or badly written.
Poor record-keeping cases in court
Dyl (2016), writing for Anthony Gold Solicitors, discussed the case of FE v St George's University Hospitals NHS Trust, where poor record keeping was an important issue in the case. The case should be read in full as it shows the impact that poor record keeping can have in a clinical negligence case.
‘While the poor record keeping in question was not the only reason the Claimant's claim was successful, it is clear from reviewing the judgment that it played a significant part in the overall evidence which was given at trial. Mrs Justice McGowan was critical of the standard of record keeping displayed by the Defendant and it is clear that the state of the medical records had an impact on the perception of the Defendant's witnesses.’
Conclusion
There are a myriad reasons for getting health care communication practices right, the main one being the safety of the patient. We have seen several Never Events in NHS England (2023) where wrong procedures took place, or the wrong patient was treated. Never Event communication errors abound, and they are unforgivable by any measure of the word. Such errors on the face of it seem simple to fix but are stubbornly persistent. They can be seen in past reports and will no doubt feature in future ones. Sadly, I fear we may be drifting towards the concept of the Common Never Event as the NHS does in some quarters seems to fail patently to learn the lessons of past adverse healthcare events.
We see in the CQC report, and in other reports of adverse incidents in maternity care, acute failings in good communication practices that need to be urgently addressed. Again, this seems to be another instance of patient safety lessons going unlearnt. Poor communication practices are a well-documented recurring problem.
In terms of good record keeping practices, the Medical Defence Union (2021) offers clear advice on good practice; Hassan and Ford (2019) and Dyl (2016) bring useful legal perspectives to the issue. Reflecting on and improving our communication practices is a personal and professional obligation. It's a fundamental prerequisite of professional practice.