The must-read stories and debate in health policy and leadership.

Realising you’ve been calling somebody the wrong name 15 minutes into a conversation is embarrassing. But, if that sort of mistake happens in a healthcare setting, the consequences can be significantly more serious — and, sadly, sometimes more tragic — than some awkwardness and a mumbled apology.

An HSJ investigation found NHS trusts logged 58,537 cases of patient misidentification in Datix or other patient safety systems between 2019 and 2023. Of these, 4,713 — an average of just under 1,000 a year — led to harm.

While most of the harm recorded was “low”, the data collected revealed 250 cases of moderate harm, 10 cases of severe harm and two deaths across the five years.

Action against Medical Accidents chief executive Paul Whiteing described patient misidentification as “a basic error for which there is no place in a modern healthcare setting”, while Patient Safety Learning CEO Helen Hughes called on NHS England to review cases nationally to identify root causes.

An NHSE spokesperson acknowledged patient misidentification “can represent clear healthcare risks”, adding: “The NHS offers expert advice and guidance to healthcare organisations on how to strengthen systems, including through implementation of barcode technology to match patients with their treatments, medications and surgical procedures.”

Stretched to breaking point

In a blistering public statement, Sarah Wollaston, the chair of Devon integrated care system, announced her resignation on Tuesday morning, saying she “did not feel able to sign off on a further cut” and that the “elastic” was already stretched too far.

The former chair of the commons health and social care select committee said the decision to quit was made “with regret” but she was “not happy as chair to sign off on the financials”.

“No point promising the unachievable, especially if only achievable with unacceptable consequences,” she wrote.

She was also critical of NHSE’s financial regime for punishing areas with deficits and for raiding capital budgets and also in delays accessing it.

This will be sorely felt by Devon ICS because one of its hospitals, North Devon District Hospital in Barnstaple, was included in the government’s “40 new hospitals” pledge in 2019 for redevelopment between 2025 and 2030. However, it has since been delayed, prompting warnings about safety due to its ageing estate.

It has been said Dr Wollaston’s departure will be a loss to the NHS (as an experienced politician and a GP) but her resignation will be tricky for a system that has already faced significant churn. Also, with such significant financial and performance problems it will certainly be hard to recruit a new chair — especially one willing to make even more cuts. 

Also on

We report that a trust has been forced to close its sterile drugs production unit due to “increasing infrastructure weakness”, risking a £3m annual bill for purchasing the medicines. And the Conservative Party has said it will consult on a disbarring scheme for NHS managers if it wins the general election.