EXCLUSIVE: NHS shake-up hampers oversight of serious incidents

The news follows the publication of the Mid Staffordshire Foundation Trust public inquiry report, which warned that past structural reorganisations had hindered NHS organisations’ ability to focus on care quality and patient safety.

A report to NHS North of England’s most recent board meeting warned that at the end of December the north had 2,447 “open incidents” recorded on the strategic executive information system − the national database for the reporting of serious incidents.

Once a provider has reported an incident on the system, it cannot be “closed” until its PCT is satisfied any necessary investigations into the cause have been carried out, and an appropriate action plan developed. In some cases the commissioners may delay closure until significant recommendations have been implemented.

The report said the “rate of review and closure” in the North had slowed at the end of 2012, due in part to “the movement of staff as a result of organisational change which has reduced the available capacity within PCTs”.

It continued: “[While] progress is being made, it is becoming evident that the lack of capacity in PCTs is having an impact on the rate of closure and following up on evidence for ‘further assurance’.”

“Significant numbers” of open incidents would be handed over to the local area teams of the NHS Commissioning Board and clinical commissioning groups that take over from strategic health authorities and PCTs in April, the paper added. It warned that these new organisations “may not have the capacity or capability to manage the volume”.

The report, by NHS North of England chief nurse Gill Harris and medical director Stephen Singleton, estimated the region would have 2,000 incidents still open on 31 March.

NHS Confederation associate nursing director Ruth Holt told HSJ that managing and learning from serious untoward incidents was a “hugely important part of ensuring safe services” and it was “essential that providers and commissioners are swiftly able to learn the lessons from these incidents”.

She added: “When CCGs become the local accountable commissioners in April 2013, it is critical that the NHS’s organisational memory, including follow-up on serious untoward incidents, is not lost. This reinforces the need for robust transitional arrangements as CCGs… take on their full responsibilities later this year.”

Ms Harris told HSJ it was NHS North of England’s “standard procedure to identify any potential risks” and “mitigate these with an action plan”. She added that since the publication of her report, “work has continued in line with this action plan to address the issues identified”.