Repetition of error is a strong and striking feature of patient safety in the NHS. The fact that the same errors are often repeated by health professionals and that lessons from past adverse events appear to go unlearnt is most concerning. NHS maternity care and Never Events are particular contemporary instances of this problem but the same problems can be seen in other clinical care areas and can be traced back well over two decades, to the seminal publication, An Organisation with a Memory (Department of Health, 2000). Effecting positive change and improvement in NHS patient safety is easier said than done.
We need to move away from the rhetoric of saying that we know and understand the nature of the patient safety problems in the NHS, that we are taking steps to deal with the issues and that matters are improving. It is possible to say that when you have demonstrable proof and measurement of improvement and we have this in some clinical areas but in many we do not. Looking at reports from the Care Quality Commission (CQC) a different, real-time picture of patient safety can emerge.
The problems in East Kent
The problems with maternity and neonatal services in East Kent, as highlighted by the independent review, are a salutary reminder of the terrible patient safety issues that can occur:
‘Had care been given to the nationally recognised standards, the outcome could have been different in 97, or 48%, of the 202 cases assessed by the Panel, and the outcome could have been different in 45 of the 65 baby deaths, or 69% of these cases. The Panel has not been able to detect any discernible improvement in outcomes or suboptimal care, as evidenced by the cases assessed over the period from 2009 to 2020.’
Kirkup (2022) identified some chronic patient safety problems, which included:
- Gross failures of teamworking across the trust's maternity services, dysfunctional in nature
- Failures of professionalism
- Failures of compassion
- Failures to listen
- Bullying and harassment were frequently reported.
The CQC subsequently found repeated patient safety problems during inspections:
‘Assessing and responding to patient risk. Staff had tools available to assess, manage, monitor, and respond to the safety of women and babies, however these were not used consistently or effectively.’
The inspection report states that women who required information and support were poorly served. That all enquiries to the service came through the triage phone – the service did not have a pregnancy helpline. Record keeping was also a problem:
‘Records: Staff did not always maintain complete detailed records of women's care and treatment. Records were stored securely and easily available to all staff providing care. Paper records were not kept securely in handheld records causing a risk they could be lost or mislaid.’
Another concern that feeds into this column's overall theme of learning from past adverse healthcare events is this finding:
‘Incidents: The service did not always manage safety incidents well and there were delays in investigations being completed to identify actions and learning. Staff recognised and reported incidents and near misses. Learning from incidents was not always effectively managed.’
The CQC (2023) report did have some positive themes such as staff understanding their responsibilities under the duty of candour and also the need to be open and transparent with women and their families:
‘They told us they would offer the woman an apology and raise any concerns with their line managers who they thought would initiate the duty of candour process.’
The CQC noted that the service was developing processes to share feedback from investigation of incidents, and that trust-wide learning was in its infancy. There are both positives and negatives in the CQC inspection report and it should not be assumed that the trust has not learned from the independent review. Some lessons have been clearly learnt but the pace of learning must quicken and the learning become more comprehensive. The CQC's (2023) comment about trust-wide learning being in its infancy is an interesting one to reflect on further.
Not all singing from the same patient safety song sheet
In discussing NHS patient safety and trust progress towards culture development it is important to remember that this will not change overnight and cannot be mandated as such to do so in such a short time frame. Change will be incremental in nature and pace. This is the pattern that has emerged when we look across NHS patient safety over several years. This must be because of the essential nature of NHS trusts and the complex nature of healthcare delivery and treatment generally. To effectively manage the patient safety culture development process there needs to be more of a general recognition that NHS trusts are not all at the same stage of development. Some are much more advanced than others in patient safety processes, some need more help than others. This is true of any type of organisation – some will always be more mature than others.
This pattern of thinking should not be seen as a general ‘get out of jail card’ for poorly performing trusts, an excuse to tolerate poor standards. Poor care standards should always publicly be called out, as the CQC does. When this happens, we need to look beyond the banner headlines of the general media when crises are reported, avoiding knee-jerk reactions. We need to take a detailed look at the reports in a balanced way, looking for both good and bad findings. We need to assess trust patient safety maturity and work steadfastly to implement change. There are no quick fixes.
Some degree of error in health care is inevitable as we all make mistakes, and nobody is infallible. The best we can hope for is to effectively manage clinical risk. NHS trusts are also complex places with organisational cultures that range widely in terms of effectiveness. These have to be negotiated by any change-driving process.
NHS Never Events
Never Events demonstrate again the cyclical nature of patient safety error in the NHS and the need to break the cycle by learning, implementing the lessons from adverse health care events.
Professor Ted Baker, in the forward to the CQC's seminal report, ‘Opening the Door to Change, said:
‘What sets Never Events apart is that they are believed to be wholly preventable by the implementation of the appropriate safety protocols. Despite this preventability, the number of Never Events has not fallen. About 500 times each year we are not preventing the preventable. That means that around 500 patients are suffering unnecessary harm.’
The quote above is still relevant today as it was in 2018. Matters don't appear to have changed much in regard to the occurrence and type of Never Events. Some commentators I have met have coined the term ‘Common Never Events’ and looking at the reports over the years, such a conclusion can well be drawn. Never Events are stubbornly persistent when NHS data reports over the years are analysed (https://www.england.nhs.uk/patient-safety/never-events-data) despite seemingly best efforts to reduce them.
NHS England (2023) has produced provisional Never Event data for the year 1 April 2022 to 31 March 2023. Not much seems to have changed with regard to the level of occurrence and type of Never Events compared with previous years:
‘384 Serious Incidents appeared to meet the definition of a Never Event in the Never Events list 2018 (published 28 February 2018) and had an incident date between 1 April 2022 and 31 March 2023; this number is subject to change as local investigations are completed.’
Contrasting these 384 figures with previous years, in 2021/22 there were 407 Never Events, in 2020/21, 364, and in 2018/19, 496.
Professor Ted Baker talked about approximately 500 Never Events annually (CQC, 2018). As a ballpark figure that is fairly accurate given these figures from a peak in 2018/2019. There is a bit of a see-saw in numbers but the broad number of them is evident. What is also concerning is the number of Never Events broken down by individual trusts, some have notably high figures. In the latest figures two trusts have 10 Never Events recorded against them (NHS England, 2023).
In terms of the official list of Never Events by type of incident these include:
- 169 wrong site surgery
- 96 retained foreign object post procedure
- 42 wrong implant/prosthesis
- 31 misplaced naso- or orogastric tubes and feed administered.
Never Events, basically, should never happen but unfortunately, they do, and the numbers remain stubbornly high. This raises again the issue of learning from past Never Events and changing practice.
Conclusion
Repetition of patient safety error and failing to learn the lessons from adverse events is an endemic problem in the NHS and has been so for several years, right up to the present. In terms of Never Events these are highly recurrent patient safety care failings. There have been failures to learn from adverse events – there are no easy answers to solving the problems identified.
In attempting to deal with these issues I would advocate that we also need to take into account the fact that NHS trusts are at different levels of maturity when it comes to patient safety culture development, with some being more advanced than others. The size and complexity, organic organisational nature of NHS trusts should also be factored in.
There can, however, be no excuses for poor, unsafe care. Poor quality, unsafe care should not be tolerated in any way and must be publicly called out and urgent change demanded. Patients' interests should never be compromised. The stark reality is that, reading from past patient safety reports, some NHS trusts will be quicker to respond to patient safety challenges than others. In some regions of England, trust-wide learning can still be said to be in its infancy (CQC, 2023).