Archived News

NHS "Not Learning From Errors"

25 September 2006

By Chris Gooderidge, Senior Litigation Partner
Harris Cartier LLP, Solicitors

A report by the Committee of Public Accounts, the Parliamentary Spending Watchdog, describes the performance of the National Patient's Safety Agency, which was set up to improve safety in health matters, as "extremely weak" and "dysfunctional".

In 2004 – 2005 there were more than 1.2 million safety incidents and near misses, half of which could have been avoided if Health Trusts had learned from past mistakes.

The report, which is based on work by the National Audit Office and evidence from the Department of Health, the Safety Agency and the Chief Medical officer, concludes that a culture of secrecy and inadequate safety regulations is preventing error reduction in the NHS.

A total of 974,000 incidents were reported to the Agency in 2004-5, but these represented only about three-quarters of the actual total, the committee found. An average of 22 per cent of incidents go unreported, most of which were medication errors and incidents leading to serious harm.

Edward Leigh, Chairman of the Committee, said "These statistics would be terrifying enough without our learning that there is undoubtedly substantial under-reporting of serious incidents and deaths.... the NHS simply has no idea how many people die each year from patient safety incidents".

"What this points to are two related and deep-seated failures. One is the failure of the NHS to secure accurate information on serious incidents and deaths. The other is the failure on a staggering scale to learn from previous experience".

A report "A Safer Place for Patients: Learning to Improve Patient Safety" estimates that one in ten patients admitted to hospitals in developed countries are unintentionally harmed. This shows the urgent need for an effective system. The report added that "a few Trusts have formally evaluated their safety culture" but insufficient progress has been made on achieving targets set out by the Department of Health".

The NHS treats a million people every 36 hours, which means that some errors are inevitable but clearly the present number of errors is totally unacceptable.

Susan Williams, Joint Chief Executive of the Safety Agency said that progress had been made but more was needed to ensure "even safer healthcare".

The report also refers to data showing that less than a quarter of Trusts routinely informed patients involved in a reported incident.

We in the Clinical Negligence Group at Harris Cartier see this very often in our work.

Many Clients who come to us for help are clear that they have only done so because they have not received an explanation for adverse outcomes, including where there has been the most severe injury, as in cases of Cerebral Palsy.

We see cases where there has been failure to advise of adverse incidents which has compounded the damage done and caused significant avoidable trauma to the patient and his or her family.

The introduction of the NHS Complaints Procedure recognises the benefit of openness from an early stage but we continue to see complaints correspondence that evades the patients' questions and fails to answer their concerns in clear and open terms. This adds insult to injury and can again cause unnecessary distress.

Proposals for reforming the approach to clinical negligence in the NHS included Statutory provisions to encourage openness in reporting adverse incidents, specifically a duty of candour requiring Clinicians and Health Service Managers to inform patients' about actions which have resulted in harm.

However, unless and until such openness is guaranteed, the process of investigating a clinical negligence claim may be the only way that patients can establish the facts relevant to their own treatment.

For further information relating to Clinical Negligence please contact Chris Gooderidge at Harris Cartier LLP on 01753 734821.