When we look at government and health regulatory publications over the last 20 years or so, a stark picture begins to emerge. The publications all seem to speak in similar tones about the same patient safety, health quality problems and challenges. Common solutions are regularly advanced but the same problems stubbornly remain.
In 2000 the seminal document on patient safety and health quality, An Organisation With a Memory, was published (Department of Health, 2000). This publication laid the foundations for patient safety policy development in the NHS and identified several key problems that are still with us today:
‘We believe that, if the NHS is successfully to modernise its approach to learning from failure, there are four key areas that must be addressed. In summary, the NHS needs to develop:
This report also discussed the need for a more open NHS culture when errors are reported. Publications in 2019 are repeating the same messages and calls. The Care Quality Commission (CQC) has recently published a report on progress made by NHS trusts in the first year of implementing national guidance on learning from deaths (CQC, 2019). This shows marked variation in how trusts are implementing the new guidance, with some clearly finding it difficult.
Poor patient safety history
The findings of the CQC (2019) report should come as no surprise—varied and patchy implementation of patient safety and health quality initiatives does seem to have been the order of the day for some considerable time. We have had major health service patient safety crisis such as Mid Staffordshire, Morecambe Bay, Gosport, and more recently Liverpool Community Health and now the Ockenden Inquiry. The Ockenden inquiry was ordered by the former health secretary, Jeremy Hunt, in 2017 and is looking at cases of poor maternity and neonatal care at Shrewsbury and Telford Hospital NHS Trust (BBC News, 2018; 2019). The reports on all these crises provide useful context within which to view the CQC report—patient safety failures can have deadly consequences.
Gosport
The report of the Gosport Independent Panel (2018) provided detailed and shocking insights into unforgivable patient safety care failings in the modern-day NHS. The Inquiry Panel found that the records showed that 456 patients died where medication—opioids—had been prescribed and administered without appropriate clinical justification.
‘The review of evidence conducted by the Panel suggests that, taking into account the missing records, there may have been a further 200 such deaths, bringing the overall total to around 650.’
Major failings in nursing care were identified; record keeping was inadequate and did not meet professional standards:
‘Nursing assessment records were incomplete or absent, or recorded no data in patients who clearly had needs; they also failed to record the clinical justification for starting continuous opioid medication.’
Some nurses also failed to speak up and report matters of concern:
‘The impression given is of a prevailing culture dominated by the clinical assistant and the consultants which overshadowed any understanding that the nurses could or should exercise their autonomous professional status.’
The Gosport Inquiry report shows a staggering number of patient safety failures to some of the most vulnerable patients in the NHS. There is a danger that readers of these patient safety crisis reports could well become de-sensitised over time to the scale of NHS patient safety problems.
Morecambe Bay
The executive summary of the Kirkup report (2015) points to the dysfunctional nature of the maternity service at Furness General Hospital (FGH) and substandard clinical competence, which led to the unnecessary deaths of some mothers and their babies:
‘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.’
A catalogue of common patient safety failings was found, including repeated failures to investigate adverse incidents, to learn lessons and implement changes. A poor working culture was noted.
‘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’
Liverpool Community Health
More recently, acute patient safety problems were revealed in Liverpool. Poor adverse incident investigation was one of the patient failings noted in the Kirkup (2018) report:
‘Other incidents, some serious, should also have been reported and investigated, but we heard repeated accounts that reporting was discouraged, investigation was poor, incidents were regularly downgraded in importance, and action planning for improvement was absent or invisible.’
Sadly, it is not difficult to find patient safety crisis reports in the NHS where unnecessary serious injury or deaths have occurred on a significant scale. The same errors, problems and solutions appear time and time again; the need to develop and maintain:
These are just some of the many common themes that have emerged in publications since An Organisation With a Memory, which is just as relevant today as it was in 2000, and a stark reminder of the challenges that the NHS must meet in order to develop and maintain an ingrained patient safety culture that puts the patient first.
NHS trust progress in investigating deaths
The latest report from the CQC (2019) follows on from Learning, Candour and Accountability (CQC, 2016), which detailed major failings and concerns about the way NHS trusts investigate and learn from the deaths of patients in their care. Following on from that report, national guidance was produced and the CQC (2019) has looked at how well trusts are doing on implementation. A number of case studies are included. Unfortunately, the CQC is still seeing the same poor issues previously identified persist in some trusts. Some are struggling with involvement and engagement with bereaved families and carers, a lack of training or concerns about repercussions on professionals, which suggests that:
‘Problems with the culture of organisations may be holding people back from making the progress needed.’
In the forward to the report, Professor Ted Baker, the Chief Inspector of Hospitals, argues that organisations need to engage with families and carers and to be open with each other. There is a need to share information and learning and not to perpetuate a culture of blame. He recognises that cultural change is not easy and that it will take some time, but also that the current pace of change is not fast enough.
Awareness of the national guidance was high, but implementation varied. In some trusts there was ad hoc engagement with families and carers, where contact had only taken place after a serious incident or complaint. Creating an open and transparent culture where people feel able to speak up without fear of retribution against them is key.
Good practice
The CQC (2019) also saw some examples of positive engagement, and set out some enablers and barriers to good practice in implementing the guidance:
As pointed out by the CQC (2019), these factors are not new. These are themes that have consistently appeared in reports dealing with patient safety and health quality over the years.
Conclusion
The NHS is running to stand still where policy and practice into carrying out investigations into adverse health events is concerned. There has been an NHS learning curve of nearly 20 years to try to put matters right but the same problems stubbornly persist. The solutions to the problems are also not new or all that complicated. To better communicate with patients and carers, to encourage staff to report errors, to provide a more transparent and blame free culture are just some improvement steps that have been advanced.
We have seen that the impact of failures in these areas can result in significant deaths, through the reports of past inquiries. Unforgivable numbers of deaths have occurred in the NHS over the years because of a failure to ingrain into the NHS a patient safety culture that puts the patient first. Professor Ted Baker stated that culture change does not happen overnight and that the pace needs to quicken in the NHS. I worry that this may be an impossible dream.