Some degree of error is always going to be inevitable in healthcare delivery. Human beings are treating other human beings with often complex equipment in challenging healthcare environments. Nobody is infallible and we all make mistakes. The best we can hope to do is to try to effectively manage risk. To do so, we need to learn the lessons from past patient safety adverse events and to change clinical practices accordingly. We need to have a learning and reflective patient safety mindset.
One of the seven strategic objectives set out in the World Health Organization's (WHO) Global Patient Safety Action Plan 2021–2030 ambitiously states:
‘SO1: Make zero avoidable harm to patients a state of mind and a rule of engagement in the planning and delivery of health care everywhere.’
The mind set of zero harm
The mindset of zero harm is commendable and all health carers should try to maintain this. However, in practice, given the complex nature of healthcare delivery in the NHS with its dependence on fallible humans, it will not always be possible to achieve zero harm, but it is a good starting point. Adverse healthcare events will continue to occur despite the best efforts of all.
The importance of good patient safety lesson learning from past adverse healthcare events is crucial to achieving a patient safety culture. Unfortunately, the NHS has poor form when it comes to learning from past events. We can see this by going back to the year 2000 and the publication of the seminal patient safety publication, An Organisation with a Memory (Department of Health (DH) (2000):
‘…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.’
Almost 24 years later and unfortunately this is still the case in some quarters of the NHS. Patient safety lessons from past adverse events have patently gone unlearnt and the same sorts of errors are being repeated. We can see this most clearly with NHS maternity care and the patient safety crises that continue to rock the NHS – such as Morecambe Bay (Kirkup, 2015) and East Kent (Kirkup, 2022), to name just two instances. In these and other maternity patient safety crises reports, we see common themes, recurrent problems that include poor leadership and teamwork, professional silos that inhibit good practice, poor communication, poor clinical practices and more.
We know what the problems are
To its credit, over time the NHS has built up an impressive knowledge base of why patient safety problems have occurred, and good policies have been drafted in response. The NHS has been no sloth when it comes to developing patient safety policies and creating regulatory frameworks.
This can be seen from the high-quality NHS patient safety and health literature, and the work of organisations such as the Care Quality Commission, the Health Services Safety Investigations Body, NHS Resolution and many others. The downside of all this activity is that it could be argued that we now have an overly complex, disjointed system of health regulation.
On the upside, we do have the NHS Patient Safety Strategy (NHS England/NHS Improvement, 2019). There is also the promising National Patient Safety Syllabus, and accompanying curriculum guidance and training programme from the Academy of Medical Royal Colleges.
An implementation gap
However, despite all this intelligence and knowledge, patient safety culture development does not sufficiently take root. As the charity Patient Safety Learning states there is an implementation gap:
‘… time and time again we find ourselves aware of issues that cause avoidable harm but not taking action to address their causes. We consider that a key reason for the persistence of avoidable harm is an “implementation gap” … the difference between what we know improves patient safety and what is done in practice.’
Patient Safety Learning, 2022:6
Sepsis
Major endemic patient safety problems continue to plague the NHS in areas such as maternity care. There are also other care areas where we can see perpetuation of the implementation gap and failure to properly learn the lessons of past adverse healthcare events. Several key recent critical patient safety reports have been published on sepsis care management.
Parliamentary and Health Service Ombudsman Report
A recent report from the Parliamentary and Health Service Ombudsman (PHSO) (2023) focuses on sepsis and recurring patient safety issues. It cites evidence from PHSO casework relating to sepsis complaints and case summaries, which include:
- Delay in diagnosing and treating sepsis after a procedure
- Failure to treat sepsis before and after a fall in hospital
- Sepsis caused by an untreated pressure ulcer.
The report cites an earlier report (PHSO, 2013) on sepsis, and notes that the issues identified a decade ago are still with us today:
‘Despite some improvements, we still see complaints where we find that someone has died from sepsis because they did not receive the right care at the right time. It is disappointing to see that the issues we identified ten years ago are still the same …’
The earlier report (PHSO, 2013:7) identified that care failures in sepsis seem to occur mainly in the first few hours when it is vital to act promptly and treat. Clinical issues identified included failure:
- To take a timely history and make a timely examination
- Do the necessary tests to quickly identify the source of infection
- Monitor regularly
- Start important treatment quickly.
The report also identified organisational issues that needed to be addressed such as:
- Providing adequate staff education and training
- Ensuring appropriate and timely senior input
- Timely referral to critical care
- Making and documenting a management plan
- Effective handover protocols.
Both reports (PHSO, 2013; 2023) are excellent documents that clearly convey patient safety issues in the critical care area, drawing themes together and highlighting the issues that need to be urgently addressed. It is concerning that, despite some improvements, only what can be termed patchy progress has been made over 10 years in dealing with the sepsis issue.
The two reports (PHSO, 2013; 2023) should be read together as they provide invaluable patient safety education and training learning material. They highlight the complaints made to the PHSO following such tragic events, as well as the incalculable human cost resulting from patient safety failures in sepsis management. The failures identified (PHSO, 2013; 2023) compound the points made over 20 years ago that the NHS needs to urgently improve patient safety lesson learning (DH, 2000).
Sepsis and Martha's Rule
Martha's Rule has been in the headlines recently, with the publication of recommendations on how it could be implemented across the NHS from Patient Safety Commissioner (2023) Henrietta Hughes.
The rule stems from the tragic death of 13-year-old Martha Mills from sepsis in 2021. There were failures in her care at King's College Hospital in London.
‘The inquest into her death heard that she would likely have survived the sepsis that killed her had consultants made a decision to move her to intensive care sooner.
Merope Mills recounted the circumstances surrounding her daughter Martha's death and the urgent need to give patients or their loved ones a right to a second clinical opinion:
‘… This rule would allow patients, parents, or caregivers to request an immediate review if the patient's health condition was getting worse or not improving as well as expected. Such a review would be carried out by a senior clinician not directly involved in the patient's care, almost certainly from ICU.’
Hughes was subsequently tasked with formulating recommendations to enact Martha's Rule in the NHS in England, which were recently made public (Patient Safety Commissioner, 2023). They include a call for a structured approach to obtaining information relating to a patient's condition directly from patients and their families at least daily. The commissioner states this will initially cover all inpatients in acute and specialist trusts. Staff should have access 24/7 to a critical care outreach team for a rapid review when they have concerns. All patients, their families, carers and advocates should also have access to the same as above. Contact mechanisms will be advertised around hospitals and more widely.
To achieve all this clinical hierarchies will need to be flattened, and staff and patients empowered. There is a need to:
‘… incentivise the right leadership behaviours across Trusts, create an environment of psychological safety for staff to raise concerns, drive civility in the workplace and support the entire healthcare system to work together towards successful implementation. It can't be done by just one part of the system; it must be done collaboratively and collegiately across the system.’
Patient Safety Commissioner, 2023
These recommendations represent a crucial step forward in actualising Martha's Rule. To implement fully this will require a marked change in organisational culture. The hurdles that Martha's Rule will need to overcome are well chronicled by Merope Mills when she describes silo thinking, poor interdepartmental relations, and teams with a particular reputation.
‘In some units consultants are still gods and it is dangerous when there is a culture that junior doctors and nurses (let alone patients and families) feel unable to challenge their decisions.’
Conclusion
Patient safety culture change will not take place overnight. It must be recognised that NHS trusts are at various levels of patient safety maturity, with some better than others. What is clear is that there are endemic, recurrent failures in patient safety that have continued for some time in key clinical areas. Critical patient safety lessons have gone unlearnt. We have seen this particularly with maternity care in several patient safety inquiry reports. Sepsis care management raises similar issues of poor patient safety lesson learning and responsive practice change.
The PHSO and PSC have both shone a powerful light on the sepsis issue and the urgent need for care practice change and improvement. Martha's Rule will be a powerful NHS culture change agent.