History has not served the NHS well when it comes to developing an effective patient safety culture. Time and time again we read reports of the same patient safety errors being made. A constant problem has been that lessons from adverse healthcare events generally go unlearnt and that practice does not change sufficiently. I have said this many times in my columns over the years and it remains so today.
In terms of the history of NHS patient safety culture development, a good starting point is the seminal report, An Organisation with a Memory (Department of Health (DH), 2000). It set the scene and tone for contemporary patient safety reform and culture development, providing a good barometer of progress towards changes in patient safety. If we could say that the NHS had made great steps since the publication of this report (DH, 2000) towards developing an ingrained patient safety culture and errors are exceptional and uncommon, then we could say strong progress had been made. However, when the report is read, we can see this is not the case. Even though it was published over two decades ago, it is as relevant today as it was then. Many adverse patient safety trends noted in 2000 remain with us in 2022. The report expressed a sentiment that remains resoundingly true:
‘Too often, valid lessons are drawn from adverse events but their implementation throughout the NHS is very patchy. Active learning is mostly confined to the individual organisation in which an adverse event occurs.’
DH, 2020: 77-78
The report (DH, 2000) noted some problems that are still familiar and current:
- Implementation and follow-up of recommendations is patchy
- Information is difficult for staff to access
- There is too often a ‘blame’ culture
- Implementation of recommendations takes a long time
- There is little or no systematic follow-up of recommendations. (DH, 2020: 76-78)
I take An Organisation with a Memory (DH, 2000) as a useful time marker of when NHS patient concerns were first being addressed publicly. When reading contemporary patient safety reports, some of the same concerns are raised once again.
Recent reports
The Professional Standards Authority (PSA) has published what I would regard as a seminal report on NHS patient safety and the way forward (PSA, 2022). It echoes some themes found in the DH (2000) report.
When you look at patient safety reports that have been published over the years, some address major, systemic, macro-type issues, including the two from the DH (2000) and PSA (2022). Others address more micro-specific, clinical issues such as those by NHS Resolution, one of which is discussed below (NHS Resolution, 2022). The PSA report (2022) is a big picture report that discusses four main themes and advances some solutions to the problems identified. The themes are:
- Tackling inequalities
- Regulating for new risks
- Facing up to the workforce crisis
- Accountability, fear, and public safety.
The report, like a number of others that came before, such as Cumberlege (2020), identifies a backdrop to these themes and big picture issues. The PSA (2022) stated:
‘Structural flaws in the safety framework: the patient and service user safety landscape are fragmented and complex. Concerns raised often fall between organisations or are left unaddressed due to jurisdiction issues or insufficient powers. Large-scale failures of care still occur frequently, and inquiries and reviews highlight similar themes and issues, with the system seemingly unable to prevent their recurrence.’
The Cumberlege report, First Do No Harm, stated:
‘We heard about a system that does not work in a joined-up fashion, and that lacks the leadership to deliver coherent and fully integrated patient safety policy directives and standards. Mistakes are perpetuated through a culture of denial, a resistance to no-blame learning, and an absence of overall effective accountability. This culture has to change, starting at ground level while being encouraged and supported from the top.’
This is not new thinking and the same views have appeared in several past reports, including one from the Care Quality Commission (CQC) (2018). This long-standing criticism of our current NHS patient safety system – that it is overly complex and fragmented, with some organisations having duplicated and overlapping functions – was usefully echoed in the PSA (2022) report.
‘Tablets of stone’ syndrome
In a sense, the NHS has for a long time suffered from what could be termed ‘a tablet of stone syndrome’ – namely, that it has taken a lot of time, money and effort to set up systems and organisations and therefore the motivation to change all this is all too slow
All these reports – and there are others that are, in a sense, singing from the same song sheet – point to serious failings in our patient safety system, which have been present for as long as I can remember.
Some solutions
PSA (2022) advances some solutions to the problems identified in the report. For example, it advocates an independent health and social care safety commissioner (or equivalent) for each UK country. The commissioner would identify current, and emerging and potential risks across the health and social care systems. This individual, the report states, would bring about the necessary actions across organisations. They would also co-ordinate public inquiries and reviews and monitor how recommendations are implemented.
The report advances solutions to deal with the four themes identified, including a sector-wide initiative to improve collection, analysis and sharing of demographic data of complaints to help foster understanding and tackle inequalities.
Carefully crafted
The report is carefully crafted, detailed and thorough, and it should be read by all those concerned with patient safety and health quality in the NHS. While it traverses some well-worn old ground and picks up some decade-old issues, it captures these issues and put them in a useful, thought-provoking, contemporary perspective.
To implement fully the changes proposed in the report would be a Herculean task, as there would be so much to do. The key will be to pick out certain proposals and to work through them, hopefully at pace. The PSA (2022) provides an important agenda for urgent NHS patient safety change and is to be welcomed.
NHS Resolution: clinical negligence claims in emergency care
Moving away from broad, big picture-type themes to the equally valuable closed legal claims analysis-type reports, it is clear that these are valuable, real-time patient safety tools that address common themes and offer important solutions. NHS Resolution has published three reports that explore the link between litigation claims and the emergency department (ED).
NHS Resolution identifies common themes and makes recommendations to help prevent further adverse incidents. The first report on high-value and fatality-related claims over £1 million (NHS Resolution, 2022) is discussed below. The other two will be the subject of a subsequent column.
The report begins with a general overview of ED legal claims and the varied nature of emergency care when patients present with many different symptoms and conditions. The ED is also often the first port of call for many people seeking care, and demand has significantly grown over the past few years. We have an ageing population, which makes increasing demands on our EDs. The report sets out some important statistics:
‘In 2020/21, clinical negligence claims associated with the Emergency Department (ED) accounted for 11% of the total number of claims notified to NHS Resolution and 5% of the total estimated value of all claims notified. In total the value of notified claims equated to £321.98 million including both estimated damages and the legal costs. The reported value of these claims is third next to obstetrics and paediatrics.’
The report examines 16 high-value closed claims, where damages of £1 million or more were awarded. Taken together, the total claim value amounted to £33 million. In the category of fatalities, 86 claims were examined, totalling £5.8 million. The report provides a summary of findings.
High-value claims
The average damage awarded under this heading was £2 069 029 and the themes identified were as follows:
‘Missed diagnosis (which includes failure to investigate) was common to all the high value claims: spinal (n=8) and cerebral (n=4) related misdiagnoses were the most common clinical areas for claims.’
Fatalities
The report states that the average damages paid to the claimants was £45 284:
‘Missed diagnosis was identified in >80% of claims and the remainder were related to iatrogenic harm.’
Emerging common themes
The most common recurring themes from cases reviewed under the above two headings were (NHS Resolution, 2022: 33):
- Diagnostic error – missed signs of deterioration and failure to investigate
- Missed incorrect and delayed diagnoses.
Contributing factors to diagnostics failures included:
- Problems with history taking
- Too high a threshold for arranging a definitive diagnostic investigation to confirm or refute a suspected or possible severe condition
- Incorrect weighting of history and findings, particularly the significance of severe pain
- Important negatives not documented
- Potential confounding factors not recognised
- Inadequate or misdirected physical examination
- Poor documentation.
The report also identifies other themes, including failure to recognise the significance of repeat attendance, delays in care, problems with communication, escalation and cross-specialty working, as well as outlining several national and local recommendations for clinical care that aim to improve patient safety.
Conclusion
Nurses and doctors involved with patient safety will all agree that there is a great deal of information on the subject out there. This constant flow of information makes it practically impossible for nurses and doctors to keep up to date with everything that is relevant to their clinical specialty. Selection and sifting are therefore essential.
The PSA (2022) report draws the big picture trends and provides an excellent agenda for change in NHS patient safety. The NHS Resolution (2022) report offers more discrete, focused information, outlining themes and recommendations in a key clinical area. These reports maintain excellent value and the key to success will be in the uptake of their recommendations at both workplace and NHS leadership levels, which I hope will be significant.