Hospitals in the UK could be a lot safer than they are. Unfortunately, the NHS seems to be a long way off developing a culture of care that puts the patient first. In the latest State of Care report, produced by the Care Quality Commission (CQC), the authors write that patient safety “remains the single biggest challenge for hospital providers”. The CQC, the independent regulator of health and adult social care in England, rated one in ten NHS acute trusts as inadequate for safety.
The latest patient safety failing to make headlines was the news that a premature baby was left to die in a “sluice room” at North Manchester General Hospital. Pennine Acute Hospitals NHS Trust’s review of its Royal Oldham and North Manchester General hospitals identified several “unacceptable situations”. The report condemns staff attitudes which led to another mother’s deteriorating health being wrongly attributed to mental health issues – a misdiagnosis which saw her eventually die from a “catastrophic haemorrhage”. The review also points to other cases including a baby dying because a mother’s rare blood type was not identified and a woman needing a colostomy because her condition was missed three times.
Such tragic and unforgivable patient safety failures and poor staff attitudes have been seen before in the NHS and the lessons from past errors seem to be going unlearnt. The Morecambe Bay Inquiry report, which was published in March 2015, revealed serious failures in care at the maternity unit at Furness General Hospital:
The result was avoidable harm to mothers and babies, including tragic and unnecessary deaths. What followed was a pattern of failure to recognise the nature and severity of the problem, with, in some cases, denial that any problem existed, and a series of missed opportunities to intervene that involved almost every level of the NHS.
In 2013, we had the Francis Report which investigated the terrible and tragic failures of care in Mid Staffordshire where significant numbers of patients suffered and died. This was the worst and bleakest moment in the history of the NHS.
There is a disputed estimate of how many patients died in that crisis. One report suggested that between 400 and 1,200 patients died as a result of poor care over the 50 months between January 2005 and March 2009 at Stafford hospital. There have been many more reports of NHS patient safety failures which have caused unnecessary patient death and suffering.
Not much has been learned
History has not served the NHS well in this regard. As far back as 2000, patient safety issues were being identified as a serious problem in the NHS by the Department of Health. The DoH’s seminal report, Organisation with a Memory, set the patient safety policy development strategy for the NHS. It found then:
Inquiries and incident investigations determine that “the lessons must be learned”, but the evidence suggests that the NHS as a whole is not good at doing so.
In 2016, going forward to 2017, 17 years on from the publication of Organisation with a Memory, it’s questionable whether the NHS is any better at learning from patient safety errors.
The CQC report and the patient safety maternity incidents in Manchester reported by the BBC are all stark reminders of what can go wrong in the NHS and raise again the question of why and what is being done about it.
Post Francis, successive governments have worked hard to develop and implement good patient safety policies and strategies, but this has not been enough. To bring about a lasting change that is patient focused, healthcare professionals need to develop more patient focused caring attitudes, a new sense of patient-focused professionalism.
For nearly 17 years, and some would say from even before that, health quality and patient safety improvement strategies have been centrally directed from the DoH and by other bodies, but these have all failed to deliver an effective and lasting patient-focused NHS safety culture. More attention should now be paid to changing and developing the NHS patient safety care culture at the local level.