In terms of transparency and accountability the NHS is excellent at producing insightful, well-produced reports on health quality and patient safety, which it does on a regular basis. It is an impossible task for nurses and doctors to keep up to date with all the materials published and maintain heavy workloads in resource-constrained environments. It is also hard for staff to know which reports to prioritise.
The NHS maintains numerous websites containing patient safety information because many NHS organisations have responsibilities in this area. Quality and patient safety permeate all aspects of NHS work. There is an urgent need, as I have said in previous columns, for the NHS to create a one-stop patient safety information hub, which would collect reports from all NHS and other important global sites, putting everything in one accessible place.
Personal patient safety updating regime
All nurses and doctors must demonstrate a reasonable personal patient safety updating regimen within their own clinical practice areas. The codes of professional conduct require reflective, safe, evidence-based practice and the common law of tort also demands this. It is the hallmark of being a profession that you keep up to date and informed about patient safety reports. One way to do this is to read the professional journals of your clinical specialty.
Below is a snapshot of some recent NHS patient safety and health quality reports from some key organisations, which identifies some themes and trends.
NHS complaints
Complaints are a good barometer of patient safety and health quality. Nobody likes being complained against, but this is a factor of everyday life, whatever profession or industry you are in. Complaints should be analysed for trends and themes because they may indicate failings in certain areas of practice.
They should also be viewed as useful consumer and customer feedback. Many retailers view complaints positively as constituting useful marketing feedback that can inform new products and services development. Unfortunately, the NHS experience with complaints is not that positive, and defensive attitudes prevail:
‘There seems to be a prevailing attitude of defensiveness in the NHS when things go wrong, and a reluctance to admit mistakes, which is likely to be leading to more clinical negligence claims.’
Failing to handle a patient complaint properly can result in the patient being forced to take matters further and could well lead them to take legal action to resolve issues. Most often, however, patients simply want an explanation of what occurred, an apology and an assurance that what happened to them will not happen to anyone else.
NHS Digital complaints reports
NHS Digital produces regular data reports on written complaints in the NHS that include key facts, such as:
‘The total number of all reported written complaints in 2017–18 was 208 626. This is the equivalent to 4012 written complaints a week or 572 complaints per day … The total number of all reported primary care written complaints has increased by 4058 (4.5 per cent) from 90 579 in 2016–17 to 94 637 in 2017–18.’
An interesting takeaway point from the above quote is the figure of 572 written complaints a day.
NHS Digital produces a quarterly account of written complaints made by, or on behalf of, patients about NHS hospital and community health services in England. The latest report (NHS Digital, 2019) states that between 1 January and 31 March 2019 (Q4) there were 29 507 new written complaints about hospital and community health services compared with 28 019 in Q3. Over this period 27 054 complaints were resolved: 8684 (32.1%) were upheld; 8453 (31.2%) partially upheld; and 9917 (36.7%) were not upheld.
The report breaks down the 29 507 new complaints into discrete areas: service, subject and profession. There were 38 417 complaints by service area, the largest proportion being attributable to inpatient services with 33.2% (12 748), followed by outpatient services at 22.0% (8465). The report states that there were 4886 complaints by subject area, of which 27.0% (13 210) were about clinical treatment:
‘The largest proportion by all subject areas were about communication with 15.6% (7620) then patient care including nutrition/hydration at 12.5% (6115).’
There were 42 648 complaints by profession: the largest number was attributable to medical staff with 41.4% (17 651), and nursing came second with 23.3% (9929).
Communication
It is particularly noteworthy that ‘communication’ features as the prime subject matter of patients' complaints in NHS Digital (2019). I would argue that poor communication is probably one of the leading causes, if not the leading cause, of complaints related to patient safety adverse events, as well as litigation in the NHS.
Parliamentary and Health Service Ombudsman (PHSO) reports over the years have consistently catalogued communication failings as the leading cause of complaints. Many court cases have featured such failings as the cause of negligent treatment. The failure may be between health carers or health carers and patients, in failing to pass key information to appropriate people about the condition of the patient or even the site of an operation. Other complaints include mixing up patients' names, not recording observations, numerical errors, placing the decimal point in the wrong place etc. There are well over 25 years' worth of reports documenting ‘communication’ as a leading patient safety and complaint area.
As is so often the case in the NHS, lessons are not learnt from past events, errors continue to occur and practice is not changed. There is a direct correlation between failures in communication, healthcare litigation and NHS complaints.
Ombudsman's reports
The PHSO reports of investigations have been a consistently good barometer of patient safety and health quality in the NHS, and are important professional updating tools. The PHSO makes the final decisions on complaints that have not been resolved by the NHS in England, UK government departments and other public organisations. The reports are detailed and cover key themes and trends.
The PHSO website and reports are an essential source of patient safety information and, over the years, they have covered many clinical areas. A recent report (PHSO, 2019) covers missed opportunities: what lessons can be learnt from failings at the North Essex Partnership (NEP) University Foundation Trust. This report concerns the PHSO investigation into the deaths of two vulnerable young men and the significant failings in the mental health care and treatment they received. The report is detailed and spans 22 pages. It covers the background to the cases, the timeline of events, PHSO recommendations, PHSO investigation details, and the findings in each case. The report presents a window on events that show critical care and patient safety failings, and the lessons that can be learnt.
Mr R's case
The PHSO found failings in the care and treatment provided to Mr R, which, according to the report, meant there were missed opportunities to mitigate the risk of him taking his own life. Mr R died on the evening of 28 December 2008 after being found in an unresponsive state in his room. The report lists key subject headings of failures, medication, ward leave, physical restraint, care and treatment. No issue was found with the dose of medication prescribed, but specialist advice should have been taken or a full-risk assessment carried out before prescribing atomoxetine, and there was a failure to monitor Mr R for side effects:
‘Staff did not always record the rationale for giving lorazepam and its effect on Mr R.’
Ward leave was not managed properly within established policy. Several failings occurred, including granting overnight leave to Mr R without any documented rationale or undertaking an appropriate risk assessment. Regarding physical restraint, staff did not do enough to de-escalate the situation and, according to the report, behaved unprofessionally during the restraint, shouting at each other and using inappropriate language. In terms of care and treatment on 28 December 2008, Mr R's initial care plan had not been updated and the assessment and management of risk was inadequate:
‘Mr R had been admitted at risk of suicide but there was no mitigation plan in place other than “as needed” lorazepam. NEP acknowledged through its own investigation that staff had not responded adequately when Mr R threatened to harm himself.’
The ombudsman also investigated the Matthews case that occurred 4 years after Mr R's case. This case also highlights significant failures and compounds the problems identified earlier in Mr R's case.
Matthew's case
According to the report, Matthew, aged 20, had been under the care of the NEP Early Intervention in Psychosis team since 2011. He was brought in to the specialist healthcare centre as a place of safety on 7 November 2012. On 15 November staff found him hanging in his room and he later died after failed resuscitation attempts.
The PHSO investigation found aspects of his care and treatment were in line with relevant guidelines but there were significant care failings. Investigations were not robust enough, and the NEP was not open and honest with the family about steps taken to improve safety at the Linden Centre where he was treated and some years earlier Mr R. The report catalogues findings under headings that again include care planning, risk assessment, management, physical health and nutrition, medication, observation, record keeping, lack of timely safety improvements. Several critical care failures are identified, including Matthew's observations not being properly managed, record keeping not always being as robust as it should have been, and inadequate care taken over his physical health.
Taking the reports together
Taken together, both reports in the PHSO (2019) investigation reveal a serious catalogue of patient safety failures in mental health care and hopefully lessons will be learnt. Mental health care in the NHS still faces serious patient safety challenges despite funding uplifts. The PHSO report (2019) is an excellent document that shows how reports of investigations into complaints can work positively to influence care standards and improve patient safety by publicising cases.
Conclusion
In terms of personal professional updating and improving safety in the NHS, reports of investigations into past adverse patient safety events have an immense educational and practical value. They are excellent teaching aids and give much needed publicity to serious failures of care, ensuring public accountability for the provision of healthcare services. Reports also give insights into the current state of patient safety in the NHS, identifying trends and themes. The NHS is good at producing reports but sadly needs to improve on how it demonstrates learning from them.