Everything you need to stay up to date on patient safety and workforce, plus my take on the most important under-the-radar stories. From patient safety correspondent Shaun Lintern
How to save babies’ lives
An investigation by HSJ has exposed the failure of some NHS midwives and obstetricians to properly understand and act on warning signs in birth – leading to hundreds of cases of negligence and a £500m litigation bill for the NHS.
Our story explores the apparent inability for a significant minority of midwives to adequately interpret foetal heart rate recordings made by cardiotocograph (CTG) machines. The number of errors in recent years shows the problem is not isolated or rare – one coroner described it as “commonplace”.
More concerning was that the investigation revealed these issues have been repeatedly highlighted, with reports since 2009 concluding that a lack of ability among midwives was a key cause of clinical negligence cases. Experts stressed to HSJ that NHS trusts needed to invest in multidisciplinary training and change teams’ culture to ensure staff were constantly learning.
One example where things are going well is at Barking, Havering and Redbridge University Hospitals Trust, where investment in training, resources and new team approaches has reduced CTG errors in maternity incidents to zero in the past 11 months. In 2015-16, 75 per cent of maternity incidents involved a CTG reading error.
The government’s emphasis on learning from maternity errors and reducing the rate of stillbirth and brain injuries gives a fresh impetus to maternity units to ensure staff are properly trained, guarantee they learn from mistakes and borrow from trusts like BHR to improve.
One disappointing reaction to these issues comes from the Nursing and Midwifery Council. In its letter back to one of the coroner’s who raised concerns over midwifery CTG skills the nursing regulator said his recommendations to more rigourously assess knowledge of CTG traces by midwives when they qualify and are recruited would be “disproportionate”.
With respect to the NMC that is a disproportionate response to an issue contributing to hundreds of avoidable brain damaged babies and deaths in recent years.
A reckoning is due
Regular readers will know HSJ has tracked the link between patient safety and nursing numbers closely. There is mounting evidence of the importance of nursing roles to patient safety and the risks of expanding non-nurse roles for patient outcomes.
Policy responses from government and the NHS have been weak and in some cases, dangerous. Scrapping NICE’s work on safe staffing was a mistake and changes to student bursaries were made with little investigation of risks and without a plan B. Cuts to Health Education England’s budget have reduced trainee numbers and years of pay restraint and pressure on staff are driving many to leave. A third of nurses are nearing retirement and Brexit could push thousands more out of the NHS.
It is encouraging that after years of warnings and growing evidence there is now a united voice – from NHS Providers, the Royal College of Nursing, the Health Foundation, the Nuffield Trust and others – that workforce is a key issue that needs to be addressed by the government.
But this united front could be too little, too late. In 2012, there were warnings of a “national disaster” in the nursing workforce as cuts by strategic health authorities started to bite. We are five years on with no clear solutions and greater threats. In some cases, the threats are masquerading as solutions – like the drives to down-skill nursing roles under the impression that “anyone is better than no one”.
Turning around this situation will be expensive, time consuming and will require humility from those who stayed silent for too long. A reckoning is due on mistakes that have been made in manging the NHS workforce. It could come at great cost to patients.
Patient Safety Congress draws near
This year marks the 10th anniversary of the Patient Safety Congress, which will be at Manchester Central on 4-5 July. I am honoured to be chairing the event and this year have aimed to increase the representation of patients and families on panels.
These important voices are too easily dismissed at times, but can be key sources of learning. This year the congress will welcome several patient voices. This has been made possible thanks to the support of healthcare software company RL Solutions.
Key speakers at the congress include HSIB chief investigator Keith Conradi; French safety expert René Amalberti; health secretary Jeremy Hunt, Sir Robert Francis QC; and NHS Improvement chief executive Jim Mackey.