There is a direct correlation between poor communication practices and healthcare litigation or complaints. This can be seen in countless reports published over the years. Many reports have emphasised the need for health professionals to view record keeping as an important professional skill and not something to be fitted in as an afterthought in a fast-paced clinical environment. If corners are cut in documentation and in communicating properly, at handover for example, then this markedly increases the chances of an adverse event occurring and a resulting complaint.
I have said before that if something is not written then a judge in a court may well take the view that it never happened. Your credibility as a witness often relies on your records on the day. In a very real sense, I am stating the obvious about the need for good documentation and communication practices. It is self-evident that we all need to do these things properly as a matter of sound common-sense. Unfortunately, this needs stating repeatedly, as the issue persists in the NHS. When we look at what went wrong in a patient safety or clinical negligence case, poor record keeping, documentation or communication can often be seen as a leading cause or indeed the sole cause of the problem.
NHS Resolution regularly states the importance of good record keeping, documentation and communication practices when reporting on themes in litigation cases. In its series of reports on clinical negligence claims in emergency departments in England, failures in these aspects feature heavily.
NHS Resolution: missed fractures
According to NHS Resolution (2022a) missed fractures can occur at sites throughout the body but one injury in particular, hip fractures in older patients with a history of a fall, stood out when cases were examined.
The report considered 78 missed fracture legal claims between a date of 2015/16 and 2017/18. As well as the tragic human cost of these errors, the financial total NHS cost is high at £1 118 972. This figure includes £469 611 paid in damages and £649 361 in legal costs.
‘The following themes were identified as contributory factors to claims relating to missed fractures: diagnostic error, particularly early incorrect diagnosis of soft tissue injury. Requests for imaging, reporting, interpretation and follow up. Communication, team working and escalation. Delays in care, including specialty reviews and missed therapeutic options.’
The report is an excellent one and goes into detail about the claims in this clinical area. In terms of communication it states:
‘Additionally, there were errors made in interpretation by the EM [emergency medicine] clinician and, to a lesser extent, in formal reporting. There were a smaller number of cases of system failure where information was not communicated, thus delaying diagnosis and treatment. For example, in one case a wedge fracture was identified when an x-ray was reported 3 days after attendance at ED [the emergency department], but the report was not received by ED so recall and treatment were delayed.’
Several national and local recommendations are made, and emerging themes identified.
NHS Resolution: hospital-acquired pressure ulcers and falls
The final report discusses hospital-acquired pressure ulcers (HAPUs) and falls (NHS Resolution, 2022b). Documentation, record keeping and communication errors feature significantly. I have seen, over the years, many cases and published reports of situations where there has been no record of any risk assessment being made, incomplete or missing records and so on. If there is no record of a pressure ulcer assessment, or a mobility assessment, then it could well be viewed by a judge hearing a case that one was not carried out despite the nurse saying otherwise. It is very hard to defend a trust, nurse or doctor where there is poor or missing documentation.
The report has a section on overarching data and financial impact where it is stated that pressure ulcers remain a significant healthcare issue in the UK, with over 1300 new ulcers reported each month, affecting 200 000 people annually. The executive summary discusses 40 claims that were successful with compensation being paid relating to HAPUs and falls. Of these, 15 claims concerned pressure injury and 25 related to falls with an incident date between 1 April 2014 and 31 March 2018; the total cost of the 40 claims was £1 207 350.
‘Clinical themes for pressure injury and falls included failure to complete or accurately assess the risk of harm and implement an appropriate bundle of essential care. Documentation and communication were contributing factors in most of the incidents, compounded by variation in the standard of incident reporting and investigation.’
HAPUs: Detailed analysis
Chapter 2 considers several matters relating to HAPUs, which include the anatomical site of all pressure ulcers, category, age, gender, comorbidities, timing of attendance, risk assessments, nursing care and nursing documentation. Some concerning findings about the quality of nursing care are stated:
‘There was lack of evidence in all the claims we examined to support delivery of good standards of nursing care to prevent skin damage, which included regular repositioning, use of pressure relieving aids and regular monitoring of pressure areas.’
The report states that substandard nursing care continued into other clinical areas in every case, which directly contributed to the deterioration of the HAPU, and ‘to the success of the claims’ (NHS Resolution, 2022b:29).
There is a discussion of nursing documentation, which varied across all 15 claims:
‘One trust had an intentional rounding checklist as part of the nursing care records to be undertaken by HCAs [healthcare assistants] every two hours, but it was not consistently completed. Most trusts had a dedicated section within the ED clinical notes for nurses to calculate risk for pressure injury and yet they were not always completed. Not all entries were dated and timed and therefore it was unclear when specific events occurred…’
It is concerning that documentation and communication practices were contributing factors in most of the incidents in the reports. These issues are the simplest to fix and these types of errors strike at the heart of nursing and medical professionalism. These are simple, basic errors, which all professionals exercising due care and attention should not be making. The organisation that the staff are working within may also be at fault in failing to provide a robust patient safety culture:
‘The majority of these claims relate to systems and processes which influence delivery of effective nursing care and how organisations learn when things go wrong.’
Falls: detailed analysis
Falls-related claims in the emergency department are discussed in some detail in Chapter 3. The focus is on closed settled claims with damages paid.
‘With an incident date in the financial years of 2014/15 to 2017/18, NHS Resolution paid £914,375 to settle the 25 falls claims in ED … The mean average amount of damages paid was £19,428 – with actual compensation payments ranging from £2,000 to £125,000.’
A detailed analysis of patient falls in the emergency department considers aspects such as the patient journey, age and gender, comorbidities, risk assessments and nursing care.
Most patients (n=20) did not have a risk assessment despite the average time in the emergency department being over 7 hours. When risk assessments were undertaken (n=5), two were complete with every question answered but none were accurate:
‘This means their level of risk was erroneous and effective nursing care could therefore not be planned or implemented. One assessment was completed when the patient was being discharged/transferred.’
There is a discussion of ‘intentional rounding tools’ or ‘comfort rounds’ not being routinely and regularly undertaken:
‘There was no evidence in 75% of the claims we reviewed to support the conclusion that these patients had their nutrition and hydration needs met. No patients received dedicated 1:1 supervision while in ED despite many patients having impaired cognition.’
The report also points out that there was no evidence in NHS Resolution documentation to suggest bedrail assessments were undertaken. There was also a lack of evidence that patients received all the elements of care usually found on an ‘intentional rounding tool’(NHS Resolution, 2022b: 39).
Four emerging themes from HAPU and falls claims are identified:
- Risk assessments
- Proactive nursing care and closer observation
- Communication
- Reporting and investigation of incidents.
In terms of the second theme the report points to the lack of proactive nursing intervention and an absence of close observation of high-risk patients in all 40 claims discussed (NHS Resolution, 2022b: 45).
Conclusion
These are both excellent reports giving real-time practical examples of major defects in patient safety in three core clinical areas. They are also excellent teaching tools for education and training. The types of errors made in these reports are to my mind very basic ones and could have been easily avoided. Errors can be seen to lay with the nurse and doctor but also failings in the environment of care and hospital systems cannot be ignored. There are a whole mix of issues at play here.
It is impossible to read these reports without feeling concerned, even alarmed, at the findings. Basic errors in care have been discussed, which have all happened before. One patient died from the fall, which compounds the seriousness of these issues. However, I am cautiously optimistic that the local and national recommendations made within these reports will make some positive impact on care quality in the clinical areas discussed.