Over the years nobody has ever said that developing a patient safety culture in the NHS was going to be easy. It has proved and still is proving exceptionally difficult. I say this because of the frequency of major patient safety crises that occur in the NHS and the constant reminders of systemic problems.
The Parliamentary and Health Service Ombudsman (PHSO) (2023) in a controversially titled report, ‘Broken Trust: Making patient safety more than just a promise’, clearly laid out the patient safety challenges that face the NHS and what needs to be done to improve matters. We know what the issues are and most often the solutions. However, as the charity, Patient Safety Learning (2022), and the PHSO have noted, there is an implementation gap between theory and practice in NHS patient safety.
Breaking the cycle of unlearning
Improvement recommendations are made after a patient safety crisis, often repeated ones, but the system does not change much or at all. Errors are repeated, lessons go unlearnt. This might seem a pessimistic appraisal of the patient safety culture development efforts but after reading some recent reports, they have not given me cause for immediate optimism. There are the green shoots of some positive developments but there are still significant challenges ahead. In this column I will discuss several recent patient safety reports that illustrate, in my view, the enormity of the patient safety challenges that face the NHS.
Retained swabs following invasive procedures
The Health Services Safety Investigations Body (HSSIB) (2023) recently published an interim report exploring themes relating to retained swabs following invasive procedures – classed as a Never Event. Continuing work started by its predecessor, the Healthcare Safety Investigations Branch (HSIB), it analysed and identified common themes in 31 serious incident reports from trusts dated between September 2019 and September 2022. The thematic analysis identified several common characteristics surrounding these Never Events, including:
- Responsibility for swab counts
- Communication of information about swabs
- Visibility of swabs
- Make-up of the operating theatre team
- Timing of the count and its confirmation at Sign Out
- Type and duration of the surgical procedure
- Professional culture and practice
- Distractions and interruptions
- Competing tasks
- Time pressure
- Time of day
- Clarity of policies and procedure.
The report goes into these themes in more detail and the findings are concerning. They show basic errors occurring with profound consequences for the patient, which should not be happening in a modern-day NHS. In many senses of the word, these errors are unforgivable. There was confusion about who was responsible for the reconciliation of items including surgical swabs, and challenges in communication between operating theatre staff, such as ‘communication about the count being misunderstood among the operating theatre team’ (HSSIB, 2023: 10), communication going unacknowledged or staff not feeling confident to speak up.
The report notes that in some serious incident reports there was a culture of practice among consultant surgeons of leaving the operating theatre before a procedure was completed:
‘This meant that the consultant surgeon was not present when the final swab count was completed, or for the World Health Organization (WHO) surgical safety checklist … when it is confirmed that the swab, instrument and needle counts are complete.’
The report found evidence throughout the serious incident reports that staff were distracted, interrupted or that their attention was focused elsewhere. Time pressure meant that tasks could be rushed or missed. Incidents were more common in procedures that finished in the afternoon (2 pm) and early evening (7 pm).
A safety recommendation (R/2023/012) is made, that NHS England incorporates the findings of the report into its review of Never Events policy. The next statement in this recommendation is most concerning:
‘… with specific focus on considering removing retained surgical swabs as a sub-set of retained foreign object Never Events.’
Why remove swabs from the Never Event category?
To fully understand why the HSSIB says this, it is important to read an earlier report from the HSIB (2021). In that report there was a safety recommendation (R/2021/111) stating that the official Never Events List should be revised to remove some Never Events that do not have ‘strong and systemic safety barriers’.
My view at the time was that to remove some Never Events from the list because of a lack of strong and systemic safety barriers was wrong and an exercise in semantics. I still maintain that view regarding the latest safety recommendation. Retained surgical swabs should not be removed as a sub-set of retained foreign object Never Events.
My argument is that the public and NHS staff clearly understand that there are some events in health care that should never happen. Patients should never be left with foreign bodies inside them after surgery. When we look at the themes in the latest report – distractions, poor communication, poor documentation and so on – all this compounds the need to keep these events as Never Events. Doing so would highlight their importance to staff, patients, and the public. To argue that they do not now conform to the official definitions is to miss the point. We should not be concerned with the narrow view of a definition, we need to deal with common sense definitions and work to protect patients along with staff.
Performance of maternity services in England
Brader (2024) has provided an excellent overview for the House of Lords Library of the performance of maternity services in England. The report looks at several matters including past crises, problems, solutions and policies advanced. We have seen over the years several major patient safety crises in this area, and some are ongoing. It is noted that the Care Quality Commission (CQC) has continued to raise concerns about the quality of maternity care over the years:
‘Most recently, in November 2023, around two-thirds (67%) of England's maternity units received a CQC rating of ‘requires improvement’ or ‘inadequate’ on safety, according to a BBC analysis of CQC ratings data … This compared to 55% in the previous year. The BBC highlighted that the decline in CQC safety ratings has taken place despite the introduction of various policies to transform maternity care.’
The report presents a good overview of issues and clearly highlights the concerns in this area and their continuing nature.
The Commissioner's view
The Expert Panel set up by the House of Commons Health and Social Care Committee (2023) is in the process of evaluating government progress on meeting patient safety recommendations made by public inquiries and reviews. The Patient Safety Commissioner (PSC) has submitted written evidence to the panel, which contains valuable insights and observations on the current state of patient safety in the NHS in England (PSC, 2024). There is also a discussion of the role of the PSC and recommendations to date.
Relating to the voice of the patient, the PSC draws parallels between ‘the defensive, dismissive approach that has featured in so many recent reviews' (paragraph 34) and the Post Office approach to the Horizon software problems that is currently prompting public outrage. The PSC also states that a culture persists in many places in which harm to patients is seen as inevitable, when in fact it is avoidable if proper steps are taken to identify hazards and so on. This is key, powerful testimony from an official office holder with a patient safety remit and is worth reading in full.
NHS England's response to the PHSO report
NHS England has responded to the PHSO request for an update on its progress against recommendations from the Broken Trust report (PHSO, 2023). The response is in the form of a letter (Powis and Fowler, 2024) discussing several matters including the Patient Safety Incident Response Framework (PSIRF) and how that will represent a fundamental shift in how the NHS responds to patient safety incidents for learning and improvement. The letter supports the PHSO's message on the importance of supporting a just culture and more involvement of patients and families in patient safety. Several recommendations made in the PHSO report are addressed. The letter is a useful aide-memoire of what NHS England is doing and thinking in patient safety.
Conclusion
We can see from the reports discussed that NHS patient safety culture development is not easy but rather incredibly challenging and exceedingly difficult in my view. The vast scope of NHS activities and the increasing demands made on it must all be factored into patient safety policy development discussions. Also, in evaluating patient safety initiatives and progress in the NHS we need remember that history has not served it well. Only patchy progress has been made in effective lesson learning from past patient safety crises. Serious patient safety errors can often be seen to be repeated. When we look at Never Events as just one example, we can see ingrained, systemic patient safety issues that need urgently addressing.
At the same time, we must be aware of the danger of moving the patient safety policy goal posts. I would highlight here the risk of removing the useful label of Never Events for some adverse incidents because they do not now seem to accord with definitions (HSIB, 2021; HSSIB, 2023). I worry about semantics here, obscuring what are clearly things that by anybody's reckoning should never happen – a Never Event.
NHS maternity care continues to pose major patient safety challenges. The PSC has expressed a clear and well-informed view on the nature of the challenges that must be met, and NHS England has made some progress towards developing a proper NHS patient safety culture with a promising roadmap ahead. However, as history has shown, the NHS can produce well-crafted policies but the proof is in the implementation, which over the years has been notably patchy.