The same core problems run through the four latest major reports into NHS patient safety issues, particularly in maternity and neonatal services.
APIL’s dedicated research team has analysed findings from:
The incidents investigated in these damning reports make for tragic reading. They chart terrible failings in care that resulted in numerous, needless deaths and life-changing injuries to patients, including mums and babies. Each report says shortcomings arose from multiple complex failures, rather than one single cause, and that patient safety failures stem from wider systemic and organisational issues.
Common themes which appear consistently in each report, include poor leadership and management. There was often a culture of defensiveness, bullying and fear and a failure to listen to patients and families.
There was a failure to recognise errors, escalate them, and learn from them. All too often hospitals and trusts did not abide by the legal duty of candour, which requires them to be open and honest with patients and their families when negligent care has occurred.
There were issues with staffing and inadequate training, and services were often fragmented. There was also poor oversight and regulation, and an absence of reliable systems.
The reports all come at a time when the costs of clinical negligence claims to the NHS are under scrutiny by the Government, with an announcement said to be due.
None of the failings outlined in the reports will, however, be solved by reforming the clinical negligence compensation system – it is simply the wrong target for the Government to focus on if it truly wants to cut the number of cases of needless harm caused to patients. Not a penny is paid unless a patient suffers avoidable harm. Avoid the harm and the bill for looking after injured patients will fall.
In APIL’s latest research report Clinical Negligence – the reality behind the myths, we outline our three-point plan for meaningful reform:
- Reduce the harm;
- Improve transparency;
- Improve the compensation process when patients suffer harm.
Our plan is based on years of often heartbreaking and deeply frustrating first-hand experiences of injured patients and their families, witnessed by the lawyers who represent them as they seek justice on their behalf.
Of course, there is no magic wand to instantly fix all the patient safety issues that afflict the NHS. But the starting point must be to prioritise preventing harm from happening in the first place. It will require a shift in the current culture, to one based on openness and learning lessons. A key part of this will be sharing that knowledge, good and bad, throughout the NHS, so the same mistakes are not repeated, and more patients are needlessly injured.
Transparency and openness with patients and their families must improve when poor treatment occurs. Complying with the duty of candour must become the norm. At present its implementation is sporadic at best. Patients and their families are often faced with an impenetrable wall of denial from hospitals and the trusts that run them. They have to resort to legal action to get answers they desperately need about what happened to them.
Delays to settling claims only serve to increase the NHS’s compensation bill. The longer a claim runs, the more it will cost. The claims process could be more efficient by greater collaboration between the parties, with the injured victim’s best interests front and centre of the process.
An over-arching plan with patient safety at the core, implemented through strong and co-ordinated leadership is the key. In turn, this will bring down the NHS’s clinical negligence compensation bill. But what really matters most is the cost in human suffering.
The problems are well established and out in the open. A line in the sand must now be drawn and change effected, finally.