The year 2019 was another bumper year for patient safety policy developments and crises. Some major patient safety publications were produced, and stories of patient safety crisis continued to regularly hit the headlines. Many of these were covered over the year in my columns for BJN. As a regular commentator on patient safety over several years, last year was very similar to previous years in terms of the number of patient safety reports produced and the number of crises to hit the headlines of patients being injured or killed by adverse incidents.
A cycle of report writing and crisis management
The NHS and other patient safety stakeholder organisations have been consistent over the years in producing well-thought-out and articulate patient safety policy plans while at the same time major crises develop showing poor patient care. It is a never-ending cycle of report production followed by crisis management—one does seem to cancel out the other. The result is that an ingrained NHS patient safety culture, one which puts the patient at the centre of care, seems to me to have become an even more elusive and remote prospect as every year goes by. History does not serve the NHS well when it comes to efforts to develop an effective and ingrained patient safety culture. The same care issues, patient safety problems and failures are regularly repeated, and the lessons of these events go largely unlearnt.
A 2019 milestone: the new Patient Safety Strategy
The new NHS Patient Safety Strategy, (NHS England and NHS Improvement, 2019a) contains promising patient safety improvement measures that have the potential to help develop an ingrained patient safety culture, but it will be an uphill struggle to fully implement. Policy documents by themselves do not bring about change immediately and culture change does not happen overnight. The Strategy states that in order to continuously improve patient safety the NHS will build on two foundations, a patient safety culture and a patient safety system, with three strategic aims:
In terms of involvement measures this will include the creation of the first NHS system-wide, consistent patient safety syllabus, education and training framework. Also, the establishment of patient safety specialists to lead improvement across the system.
A challenge to underlying concepts
The summary for the new Strategy states:
‘Patient safety has made great progress since the publication of To err is human 20 years ago but there is much more to do. The NHS does not yet know enough about how the interplay of normal human behaviour and systems determines patient safety. The mistaken belief persists that patient safety is about individual effort.’
I would take issue with the statement that ‘great’ progress has been made with patient safety in the NHS over the last 20 years. Having researched and studied this area before the year 2000 and after, I would say that the NHS has only made measured and incremental progress. The Care Quality Commission, in its annual State of Care reports, regularly reiterates its main concern as patient safety. My columns have reported on many patient safety crises, which show a predominantly defensive NHS culture when it comes to patient safety incidents. Many of the reported errors are common ones and have been seen before in other tragedies. A read of the seminal publication, An Organisation with Memory (Expert Committee on Learning from Experience in the NHS, 2000), will reveal how far we have come in the development of an NHS patient safety culture. Many of the themes in that report published are equally applicable today.
The systems approach to patient safety is viewed as the underpinning one in NHS patient safety policy development and is discussed in the NHS Patient Safety Plan:
‘A ‘systems’ approach to error considers all relevant factors and means our pursuit of safety focuses on strategies that maximise the frequency of things going right.’
It should not be forgotten that the role of the individual nurse or doctor in patient safety is also an important, intrinsic part of the healthcare error equation. There is room for an individualistic approach as well as a systems one in NHS patient safety policy and strategy development. As professionals, nurses and doctors have individual professional and legal responsibilities for making sure that patients are not subject to adverse healthcare events.
Commentary on NRLS national patient safety incident reports
It is possible to obtain from data produced by the National Reporting and Learning System (NRLS) a sense of the level of adverse patient safety events in the NHS in England (NHS England and NHS Improvement, 2019b). This is with the caveat that the NRLS is not designed to count the actual number of incidents occurring in the NHS; it is a learning support tool. Adverse health event reporting to the NRLS is largely voluntary, ‘to encourage openness and continual increases in reporting’ (NHS England and NHS Improvement, 2019b: 2).
There were 504 593 incidents reported from January to March 2019, which represents a 3.6% increase in the number reported from January to March 2018. The report warns that an increase or decrease in reporting incidents should not be viewed as being positive or negative in terms of the safety of the NHS. More reports being made could just reflect an improvement in reporting culture—good habitual reporting practice. The figures provide a window on what is happening in NHS patient safety. The report also looks at incidents reported as occurring from April 2018 to March 2019: English NHS organisations reported 2 036 681 incidents, which is 4.9% more than from April 2017 to March 2018.
Incident category
Nationally, the top four reported incident categories were: ‘implementation of care and ongoing monitoring/review’ (14.9%), ‘patient accident’ (14.1%), ‘access, admission, transfer, discharge (including missing patient)’ (11.9%), and ‘medication’ (10.6%).
Incident care setting
The top four care settings of occurrence were: ‘acute/general hospital’ (73.2%); ‘mental health service’ (13.5%), ‘community nursing, medical and therapy service’ (11.0%) and ‘learning disabilities service ‘(0.9%).
Reported degree of harm
About three-quarters of incidents (74%) were reported as causing no harm and 23% as causing low harm. The commentary states that 2.5% of incidents were reported as causing moderate harm, 0.3% (5426 incidents) as causing severe harm and 0.2% (4568 incidents) as causing death. This pattern is consistent with data for the 12 months to March 2018.
However you look at the data, there were 4568 reported patient safety adverse events that caused the death of the patient in the NHS in England during the reporting period. To my mind, that is a very stark and disturbing finding. If we add the number of adverse health incidents that caused severe harm, then the findings become even more worrying.
Safety incidents in the news
Two significant patient safety news stories that I reported on in 2019 were the Shropshire baby death cases and the problems surrounding glaucoma appointments in Southampton.
Shrewsbury and Telford Hospital Trust
This has been called the largest maternity scandal in the history of the NHS. It was reported that dozens of babies and three mothers died on the wards of a single hospital trust. More than 50 children also suffered permanent brain damage after being deprived of oxygen during birth, and 47 other cases of sub-standard care were identified. The Independent newspaper received a copy of a leaked report on the events:
‘The Shrewsbury investigation revealed repeated clinical errors were compounded by substandard follow-up investigations that failed to ensure lessons were learnt, while bereaved families were treated with “a distinct lack of kindness and respect”.’
Lintern (2019b) also revealed that in the Shrewsbury maternity scandal the NHS has paid £50 million compensation to families whose babies died or were left with disabilities. Among the compensation cases paid by the NHS were 13 deaths and 14 cases of brain damage or cerebral palsy.
Southampton
BBC News (2019) reported that a mother of three has been awarded £3.2 million in compensation after delays in treating an eye condition led to her going permanently blind. She was seen by a consultant more than 18 months after she first noticed her sight failing, by which time it could not be reversed.
‘An internal NHS serious investigation report last year found 15 other patients were left blind or with worsened sight loss after delays in identifying their risk factors.’
Conclusion
Several other major patient safety reports and incidents hit the headlines in 2019. Sadly, the NHS is never short of incidents to report. Also, patient safety is a large national and global industry with many stakeholders keen to advance their agendas. The result is the frequent publication of many national and international reports on patient safety. The net effect of all this is that it is becoming increasingly difficult for NHS staff to keep up to date with all that is happening. The proposal described in the NHS Patient Safety Strategy to develop patient safety education and training will be of great help to NHS staff in keeping up to date in this constantly changing and developing area. To develop and drive a sustainable NHS patient safety culture, however, change needs to be systemic and seismic. Cultural change at all levels in the NHS is needed to make our health system safer and I am not sure that this is happening on the scale it needs to right now.