The COVID-19 pandemic will not always be with us and the time will come when the NHS settles back into normal activities. The pandemic may have created a new ‘normal’ and new ways of treating patients, such as by remote consultations. Clinical practice may change when the dust settles after the crisis, but a key issue will be whether there will be less avoidable patient harm, fewer ‘never events’ occurring, and fewer headline-grabbing patient safety crises.
Before COVID-19, the general media was often rocked by headlines proclaiming major patient crises. I can see no reason why those headlines will not continue when the crisis has abated. It is a sad statement to make but history has shown that major patient safety errors, causing significant avoidable patient harm, regularly appear to blot the NHS landscape. This is despite the very best efforts of government and many in the NHS to develop an ingrained patient safety culture.
The patient safety landscape after COVID-19
Walsh (2020) captures this issue well:
‘Many people have said things will never be the same after COVID-19. When it comes to patient safety, I hope they are right. If the country can rise to the challenge of COVID-19 and can come up with the billions of pounds being spent to do so, and achieve brilliant things like setting up emergency hospitals in a matter of weeks, it should be obvious that investing in our NHS to prevent the horrendous amount of avoidable harm every year makes sense. Yes, it will cost money, but it will save lives—just like we are doing with the pandemic”
Walsh (2020) quotes some research that shows the high incidence of avoidable harm in the NHS and compares this with the death toll from COVID-19 (Ramesh, 2015; NHS England and NHS Improvement, 2020).
Ramesh (2015) quoted former Secretary of State for Health and Social Care, Jeremy Hunt:
‘Hunt said the rate of avoidable deaths in hospitals was the “biggest scandal in global healthcare” and estimated that 1000 patients died needlessly each month.’
NHS England and NHS Improvement (2020) provided statistics on the reported degree of harm a patient suffered as a direct result of a patient safety incident:
‘Nationally, most incidents are reported as causing no or low harm. Almost three-quarters were reported as causing no harm (72.6%; 1 564 635) and 24.4% (525 885) as causing low harm. Only 2.5% (53 839) were reported as causing moderate harm, 0.3% (5647) as causing severe harm and 0.2% (4283) as causing death. This pattern is consistent with data for October 2017 to September 2018.’
The figures given for moderate and severe harm and death show the scale of the NHS patient safety problem. The number of people to die of COVID-19 in UK hospitals has passed 20 000 (Otte, 2020). From NHS England and NHS Improvement (2020) we have over 60 000 significant patient safety incidents, including 4283 that resulted in death. These figures show that significant avoidable patient harm persists in the NHS and dealing with this after COVID-19 will present the NHS with significant long-term challenges.
Maternity care and patient safety
To further illustrate the point made by Walsh (2020) is the case of maternity care. Acute patient safety crises in maternity care and their investigations continue to make news headlines. These reports show ingrained, systemic patient safety problems in NHS maternity care.
Shrewsbury maternity scandal
In April, the Independent, reported that hundreds of families have been sent letters as part of the investigation into poor maternity care at the Shrewsbury and Telford Hospitals NHS Trust, as inquiry cases neared 1200 (Lintern, 2020). It stated that a leaked interim investigation report noted that at least 42 babies and three mothers had died between 1979 and 2017, with more than 50 children suffering permanent brain damage. The investigation is continuing during COVID-19, with some inquiry team members reducing hours on the inquiry in order to work on the NHS frontline. Lintern (2020) stated the inquiry chair, Donna Ockenden said:
‘Many of the concerns we are looking at are amongst the most serious any of my team have seen in their entire careers.’
The East Kent maternity scandal
In April 2020 Ng (2020) reported that the East Kent maternity hospital services scandal inquiry has begun after the Independent revealed years of errors leading to baby deaths. This will be another major inquiry into maternity care and patient safety that will continue during and after the pandemic:
‘East Kent Hospitals became the centre of a maternity scandal after The Independent learned of dozens of baby deaths caused by numerous catastrophic failures in their care in January. The Independent also revealed that more than 130 babies suffered brain damage as a result of being starved of oxygen during their birth, over a 4-year period.’
This inquiry is being chaired by Dr Bill Kirkup, who chaired the Morecambe Bay inquiry (Kirkup, 2015).
Lost lessons of the Kirkup report
Kirkup (2015) identified shocking failures in maternity care. The executive summary of the report portrays the stark issues investigated and the dire consequences of patient safety failures. The maternity service at Furness General Hospital was described in the report as seriously dysfunctional in nature. Clinical competence was substandard:
‘… with deficient skills and knowledge; working relationships were extremely poor, particularly between different staff groups, such as obstetricians, paediatricians and midwives; there was a growing move amongst midwives to pursue normal childbirth “at any cost’; there were failures of risk assessment and care planning that resulted in inappropriate and unsafe care; and the response to adverse incidents was grossly deficient, with repeated failure to investigate properly and learn lessons. Together, these factors comprised a lethal mix that, we have no doubt, led to the unnecessary deaths of mothers and babies.’
The lessons for safer maternity care given in Kirkup (2015) seemingly have not permeated through the NHS. Ng (2020) and Lintern (2020) show that lessons have not been learnt.
CQC inspection report Shrewsbury and Telford Hospital NHS Trust
In April 2020, during the current COVID-19 crisis, the Care Quality Commission (CQC) published an inspection of the Shrewsbury and Telford Hospital NHS Trust (CQC, 2020). The CQC inspected several core services in two hospitals, including urgent and emergency care, medical care, maternity and surgery. The overall trust quality rating was ‘inadequate’. A previous CQC inspection took place in 2018 and an overall trust quality rating of inadequate was also given then. On reading the latest CQC report (2020), the scale of the patient safety problem facing the trust becomes very apparent.
Findings
The CQC (2020) stated in its summary of findings that staff reported that the culture was top-down and directive. Staff told the CQC about high levels of bullying, harassment and discrimination, and that the organisation was not taking adequate action to reduce this. The report stated that when staff raised concerns, they were not treated with respect. The report stated that attention to staff development and appraisal rates were improving (CQC, 2020:17).
Other findings include:
In a section dealing with urgent and emergency care:
This is just a snapshot of some concerning patient safety failings with the potential to cause severe harm or death, which will have a significant effect on local public confidence.
Conclusion
When the COVID-19 pandemic has abated and the investigations have concluded, more reports will be published with lessons to be learnt and recommendations for change.
The CQC (2020) provides another window on the importance of getting patient safety right in the NHS and that unforgivable breaches occur all too frequently. The NHS is no sloth when it comes to producing well-written and evidenced patient safety reports. My fear is that all too often another NHS patient safety crisis comes along and eclipses previous reports. There is a danger that the previous report then becomes yesterday's news. I would like to think that each NHS patient safety report is eagerly read by all those concerned with patient safety and health quality and cascaded down to staff, backed up by training where necessary. Given that many of the patient safety reports show the same or similar themes repeating themselves, I suspect this is not the case; it should be.
Patient safety must not be put on the back burner during the COVID-19 crisis. Efforts to develop and instil an ingrained patient safety culture must be maintained.