In the ‘new normal’, after the worst of the COVID-19 pandemic, two major patient safety reports have been published by the Care Quality Commission (CQC) (2020) and NHS England and NHS Improvement, (2020). Additionally, events relating to the Shrewsbury and Telford maternity care crises are developing and West Mercia Police have confirmed that they are looking ‘… into what threatens to be one of the worst scandals in the history of the NHS’ at the Shrewsbury and Telford NHS Hospital Trust (Weaver, 2020):
‘The trust's maternity services are currently subject to an independent inquiry, led by Donna Ockenden, which has identified 1170 cases over a 40-year period that warrant investigation.’
These recent publications and events have made me reflect on the statement given in the summary of the NHS Patient Safety Strategy (NHS England and NHS Improvement, 2019):
‘Patient safety has made great progress since the publication of To Err is Human 20 years ago, but there is much more to do.’
NHS patient safety progress
Looking back to 2000, I would say that is an overstatement about the progress in patient safety in the NHS. A seminal NHS publication, An Organisation with a Memory (Department of Health (DH), 2000), published around the same time as the US Institute of Medicine report To Err is Human (Kohn et al, 2000), alluded to many problems that are still with us today:
‘… the cumulative financial cost of adverse events to the NHS and to the economy is huge. Most distressing of all, such failures often have a familiar ring, displaying strong similarities to incidents which have occurred before and, in some cases, almost exactly replicating them. Many could be avoided if only the lessons of experience were properly learned.’
This quote has a very familiar ring to it because the same themes and sentiments are still expressed today and the NHS has a long way to go before it can be said to maintain an ingrained patient safety culture (CQC, 2020; NHS England and NHS Improvement, 2020; Weaver, 2020).
CQC inpatient survey for 2019
The adult inpatient survey has been conducted annually since 2004, and, as with previous CQC inpatient surveys previously discussed in BJN, a mixture of both good and bad findings was reported (CQC, 2020).
The survey asked people who were adult inpatients in hospital for at least one night during July 2019 about the care they received, particularly around issues such as person-centred care, whether fundamental needs were met and staff availability. Significant patient safety failings, also identified in previous surveys, were found. This calls into question the perennial issue of whether the NHS has learned any patient safety lessons from the past.
Findings
Person-centred care
There are both positive and negative findings about person-centred care. When asked whether their questions were answered in a way that they could understand, 80% of those patients who had had an operation during their stay replied, ‘yes completely’. The report states that this represents an increase of 5% since 2010, which does show gradual improvement over time. Of patients asked whether they had confidence and trust in the nurses or doctors treating them, 78% and 79%, respectively, replied, ‘yes, they always had confidence’. The report states on the finding:
‘This shows an increase of five percentage points since 2011 when results were below expectations for this question’
Patients were asked whether they were involved as much as they wanted to be in decisions about their care and treatment and 55% responded, ‘yes definitely’ with a further 35% saying they had been involved to some extent. One in 10 (11%) reported they had not been involved in decisions about their care and treatment as much as they wanted to be (CQC, 2020).
In my view, this can be viewed as a negative finding and improvements should be made in securing patient involvement in decisions about their care and treatment. A positive response rate of only 55% is not good enough, and does not reflect well on NHS attitudes to patient rights and autonomy. Medical and nursing paternalism should have no place in a modern NHS.
Emotional support
Patients were also asked whether they felt that they had received enough emotional support during their stay from hospital staff: 53% replied, ‘yes, always’; however, almost one-in-five (17%) patients said they did not receive enough. Only 36% responded, ‘yes definitely’ when asked whether they found a hospital staff member to talk to about their worries and fears, while over one-quarter (28%) reported that they had not. Four-fifths (81%) had not seen, or been given, any information explaining how to complain to the hospital about the care they received.
Dignity and respect
There were several survey questions asked about aspects of dignity and respect with both positive and negative findings
When asked whether patients felt, overall, that they were treated with respect and dignity during their hospital stay, 81% said, ‘yes, always’, while 90% reported ‘always’ when asked about receiving enough privacy when being treated or examined.
Of those asked whether nurses talked in front of them as if they were not there, 82% responded, ‘no’. The report states that this finding is a significant increase compared with the 2018 results, and an overall increase of 5% from 2010.
Meeting fundamental needs
Good responses were reported about the cleanliness of the hospital, choice of food and hydration.
Patient discharge from hospital
Patient information on discharge needs to improve:
‘When asked if, before they left hospital, they were given any written or printed information about what they should do or not do after leaving hospital, two in five people (40%) responded ‘no’. There has been a decline of seven percentage points since 2013 …’
The report also states that patients were asked whether they were told by a member of staff about danger signals they should watch for after they went home. A poor response was found, with almost two-in-five people (38%) responding ‘no’.
Availability of staff
Patients were asked whether, in their opinion, there were enough nurses on duty to care for them in hospital. Over half of the patients (58%) stated that there were, ‘always’ or ‘nearly always’ enough; however, 12% stated there were, ‘rarely or never’ enough nurses while 30% said there were ‘sometimes’ enough.
Summary: lessons still to be learned
The CQC report does contain both positive and negative findings, but there are clear patient safety lessons still to be learned. Many of the same problems can be seen to have been repeated year after year, particularly so with the problems associated with patient discharge from hospital.
‘Never Events’ data published
In June 2020 provisional data on ‘Never Events’ occurring between 1 and 30 April 2020 were published (NHS England and NHS Improvement, 2020). These are defined as:
‘… serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.’
The report does have a caveat in that the period reported covers the COVID-19 crisis when NHS services were refocused on COVID-19 rather than services such as planned and elective surgery. There were 15 serious incidents that appeared to meet the definition of a ‘Never Event’, but this number may change as local investigations are completed. Box 1 lists the adverse healthcare events that should not have happened. The fact that these events have also been previously reported is an acute cause for concern, as the CQC (2018) has stated:
| Wrong-site surgery | |
| Botox injections to the forehead rather than eye injection | 1 |
| Wrong side chest drain | 1 |
| Wrong site block | 1 |
| Wrong skin lesion removed | 2 |
| Nasogastric tube in respiratory tract and feed administered | 4 |
| Retained foreign object post-procedure | |
| Guidewire—vascath | 1 |
| Surgical needle | 1 |
| Vaginal swab | 2 |
| Potassium administered instead of insulin | 1 |
| Patient connected to air flowmeter rather than oxygen flowmeter | 1 |
| Total | 15 |
‘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.’
Conclusion
History has not been kind to the NHS when it comes to developing an ingrained patient safety culture. Over the years, the NHS has been littered with major patient safety crises such as the Mid Staffordshire (Francis, 2013) and Morecambe Bay (Kirkup, 2015) scandals. These types of crises have not gone away, as we now see the events of Shrewsbury and Telford beginning to unfold (Weaver, 2020).
The CQC (2020) report shows the ups and downs of patient safety in the NHS, and the challenges that must be faced. The NHS England and NHS Improvement report (2020) shows the never-ending story of ‘Never Events’. The CQC (2018) has pointed the way to properly dealing with the issues and what must change, culture-wise, in the NHS.