Unfortunately, it is never too long before a major patient safety crisis hits the NHS and we saw this recently with the Shrewsbury and Telford Hospital NHS Trust maternity scandal.
‘Hundreds of families whose babies died or were seriously injured at the Shrewsbury and Telford Hospital Trust do not even know their cases have been identified for investigation in the biggest maternity scandal to ever hit the NHS, The Independent can reveal today. Dozens of babies and three mothers died in the trust's maternity wards, where a “toxic culture” stretched back to 1979, according to an interim report leaked to The Independent this week.’
These events follow closely in the footsteps of the Morecambe Bay maternity scandal where tragic avoidable harm occurred to mothers and babies. The events at Morecambe Bay were unforgivable in an NHS that prides itself on good-quality care and an efficient, effective patient safety system.
‘Clinical competence was substandard, with deficient skills and knowledge; working relationships were extremely poor, particularly between different staff groups, such as obstetricians, paediatricians and midwives; there was a growing move amongst midwives to pursue normal childbirth ‘at any cost’; there were failures of risk assessment and care planning that resulted in inappropriate and unsafe care; and the response to adverse incidents was grossly deficient, with repeated failure to investigate properly and learn lessons.’
Dr Bill Kirkup, who led the Morecombe Bay review, has commented on the leaked Shrewsbury interim report, finding ‘unmistakable parallels’, and despairing that the lessons of Morecombe Bay were ignored in Shrewsbury and Telford—with deadly consequences (Kirkup, 2019). The events at Morecambe Bay and Shrewsbury raise the spectre of similar events unfolding at other hospitals in maternity care and whether Morecambe, Shrewsbury and Telford are not just the tip of a large iceberg?
A long way to go for a safe NHS?
The work of the Care Quality Commission (CQC) has been generally good overall in making the NHS safer and some progress has been made in developing an ingrained patient safety culture but there is still a very long way to go. Today patient safety remains the main worry of the CQC who rightly say that we need to make much more progress in this area.
It is, however, very worrying that events such as those that are reported at Shrewsbury and Telford have persisted for so long under our healthcare regulatory structure. It is very concerning that it is only now that we are learning about the actual extent of harm that has taken place. The terrible events of Shrewsbury and Telford shakes my confidence in NHS patient safety to the bone.
Alternative realities
Reflecting at the end of 2019 and at the start of 2020 on patient safety in the NHS it seems to me that there exist two alternative realities or dimensions on the subject. One ‘reality’ can be seen existing in the quality and patient safety reports of many NHS organisations and with upbeat statements on patient safety and health quality policy by politicians and others. Consider all the hype on World Patient Safety Day in September 2019 about the positive patient safety steps taking place in the NHS, and the UK as a global patient safety leader funding patient safety research in developing countries. All well and good and we do some brilliant research in the area, but we must not neglect looking into our own back yard.
The second reality is that we have the horrors of Morecambe Bay and Shrewsbury and Telford, steadfastly hoping that there are not more to be uncovered. How can we maintain authority to say what is excellence in patient safety practice, nationally and globally, when we have these horrors occurring in our own back yard? What gives us the authority to say what is good, when so much bad seems to exist in terms of patient safety in England?
There is a lot of good patient safety activity going on in the NHS, but we do seem to get it wrong in a very big way all too frequently. We cannot afford to be complacent—history does not serve the NHS well when it comes to patient safety, particularly after Mid Staffordshire and it is not beyond doubt that another Mid Staffordshire could happen again
A question of balance: clinical negligence claims
NHS Resolution (2019) has recently published a patient safety advice booklet, on surgical burns. These ‘Did you know?’ booklets contain useful information. For example:
‘From 1 April 2009 to 31 March 2019, NHS Resolution were notified of 631 clinical negligence claims relating to surgical burns to patients. Out of these 631 claims, 459 were settled, 58 were unmeritorious and 114 are still open. This has led to NHS Resolution paying £13.9m in damages and legal costs on behalf of NHS organisations.’
It goes on to state that £13.9 million would pay for 106 band 5 nurses or operating department practitioners for 5 years.
Yes, the money could well have gone on frontline resources for an NHS that has, since its inception, always faced an infinite demand for finite financial resources. The NHS can always do with more money and is still in a precarious financial position today, facing extreme challenges. This is well recognised.
It must also be recognised that avoidable patient harm has been suffered by patients in these cases and that there are two sides to every story. Compensation has been paid to valid legal claims brought by patients who have suffered harm at the hands of nurses and doctors who were meant to care for them. The NHS will have more money to pay for 106 band 5 nurses if it takes patient safety more seriously and reduces the incidences of patient harm. Patients' lawful and moral rights to sue for harm caused to them also need to be factored into any cost–benefit safety analysis, and should never be compromised.
Further food for thought is provided by NHS Resolution (2019), which gives the top five causes related to all settled claims in this area of surgical burns:
NHS Resolution (2019) is a useful publication that offers some key patient safety information in a clinical specialty where trusts are seeing significant litigation claims.
A snapshot of some clinical negligence litigation claims
Reported legal cases on clinical negligence claims are a useful education tool on risk management. An analysis of them can reveal important trends and lessons can be learnt from them. NHS Resolution publications on legal claims, such as the one discussed above, provide useful educational aids. Other sources of information are the general media, and law firms' websites.
Some recent general media reports include one from BBC News (2019), which reported in November that a patient died after a surgeon failed to disclose he had spilt stomach contents on organs that went on to be transplanted:
‘The 36-year-old died of an aneurysm caused directly by infection from a donated liver, while two other patients became ill from transplants.’
Law firm reports
Many firms of solicitors involved in litigation concerning clinical negligence have case studies on their websites. These reports provide a useful source of current information and trends on patient safety in the NHS. They are excellent educational patient safety tools. For example, Edwards (2019) discusses the five largest personal injury and medical negligence claims ever made in the UK:
Edwards (2019) states that the £37 million claim above:
‘Is documented to be the highest NHS pay-out ever awarded, whereby the boy received a lump sum in addition to annual tax-free payments to facilitate the lifelong care he requires.’
Fieldfisher solicitors (2019) also has a catalogue of clinical negligence cases that can function as patient safety educational materials. These include:
What is apparent when looking at the cases on law firm websites is that they cover a wide range of clinical specialties. There also appears to be no shortage of case studies to access. Clinical negligence continues to occur at a significant rate across all of the NHS, across different clinical specialties and across the UK as a whole.
Conclusion
Patient safety crises that result in significant patient harm and death continue to rock the NHS to its very foundations. Public confidence in our NHS will be indelibly harmed by crises such as the recent Shrewsbury and Telford maternity scandal. The NHS does seem to be chronically unable to learn from the patient safety crises and the errors of the past, of which there are many. There is no room for complacency in patient safety and we need to realise that everything is not right with our system. Too many patients are suffering from adverse healthcare events and many can be seen to be resorting to litigation to resolve disputes and to obtain compensation. This will no doubt take away much-needed resources from the NHS, but patients who have been harmed by those who were meant to care for them have a moral and legal right to sue for compensation. The solution must be that the NHS harms fewer patients and then money will be freed up to fund frontline care services.