Making the NHS safer: learning from case reports and investigations

The NHS in England has what can be termed a patient-safety-policy development, guidance-implementation roundabout. Successive governments have brought in many commendable patient safety policies and guidance publications. Some of these, however, can be seen to have fallen on fallow ground in parts of the NHS.

In some places there is a stubborn and persistent reluctance to change healthcare practices, even in the light of adverse patient safety events occurring. An overtly defensive and blame-ridden culture when errors are made pervades some areas of the NHS. Failure to change and to learn from the errors of the past has resulted in cases of clinical negligence, formal complaints and Care Quality Commission (CQC) investigations.

It is true to say that cultures do not change overnight but, in the case of the NHS, we are talking about decades. Some things never seem to change, and the same patient safety errors can be seen to be repeated time after time. Persistent and lamentable failures in patient safety continue to take place.