NHS hospitals are putting lives at risk by failing to comply with key alerts on patient safety, a report has said.
Even “rapid response” alerts telling trusts to update their procedures urgently are not complied with by the deadlines, said the study from Action against Medical Accidents (AvMA).
Dr Stuart Gray, whose father David Gray was killed by German doctor Daniel Ubani, said he found it “deeply offensive” trusts were failing to take action.
Dr Ubani gave his patient 10 times the normal dose of diamorphine, and later admitted being confused about how the drug should be used.
A report last month found the out of hours firm Take Care Now, which employed Dr Ubani, had failed to act on an alert from the National Patient Safety Agency (NPSA) on the risks associated with higher doses of diamorphine.
The company made no changes to the way diamorphine was used and stored until after Mr Gray’s death.
Today’s study, based on freedom of information requests, comes after a similar AvMA report in February found some trusts were failing to implement the standards.
The latest study found 1,242 incidences where individual patient safety alerts had not been complied with after the deadline had passed.
These included alerts on medicines, procedures such as using equipment in a way that minimises pain, surgery and the risk of overdoses.
Some 251 (63%) trusts had failed to comply with at least one alert while just 146 (37%) said they had completed all required actions or that no action was required.
Some 67 trusts had not complied with urgent rapid response alerts which had been sparked by avoidable deaths or serious injury to patients.
A total of 29 trusts had not complied with 10 or more alerts - 11 of these were foundation trusts.
Only two of 57 alerts had been complied with by all trusts. Some alerts were years past the deadline for completion.
A spokesman for the NPSA said: “Whilst, of course, we would like every NHS organisation to report complete compliance with our alerts as well as those issued by other bodies, we are pleased that almost all NHS organisations have reported completion with the vast majority of alerts (completion is 94%).
“We do feel that the report does misrepresent the hard work and professionalism by clinicians who have worked hard to make sustained changes or adjusted their working practices during these challenging times.”
He said delivering safe services was of paramount important to the NHS.
“However, we are also aware that this may take some organisations longer to implement than others because of staffing levels, structural and cultural differences.
“When this happens, we would always offer support to those organisations.”
“We expect all NHS trusts to comply with safety alerts, including recording that action has been taken, in order to minimise any risks in the future.”
Today’s report named trusts with 10 or more outstanding patient safety alerts.
- Walsall Teaching PCT 23
- Sandwell Mental Health and Social Care NHS Foundation Trust 21
- Worcestershire Acute Hospitals NHS Trust 20
- York Hospitals NHS Foundation Trust 20
- Barts and The London NHS Trust 19
- Tameside Hospital NHS Foundation Trust 19
- Stockport NHS Foundation Trust 18
- Sandwell and West Birmingham Hospitals NHS Trust 17
- The Lewisham Hospital NHS Trust 17
- Maidstone and Tunbridge Wells NHS Trust 16
- Sherwood Forest Hospitals NHS Foundation Trust 15
- Aintree University Hospitals NHS Foundation Trust 14
- Barnsley Hospital NHS Foundation Trust 14
- Royal Free Hampstead NHS Trust 14
- Mid Cheshire Hospitals NHS Foundation Trust 13
- Harrogate and District NHS Foundation Trust 12
- Rotherham PCT 12
- Dorset County Hospital NHS Foundation Trust 11
- James Paget University Hospitals NHS Foundation Trust 11
- Lambeth PCT 11
- Mid Yorkshire Hospitals NHS Trust 11
- North Yorkshire and York PCT 11
- Plymouth Hospitals NHS Trust 11
- Winchester and Eastleigh Healthcare NHS Trust 11
- East Kent Hospitals University NHS Foundation Trust 10
- Hull and East Yorkshire Hospitals NHS Trust 10
- Manchester Mental Health and Social Care Trust 10
- North West London Hospitals NHS Trust 10
- South Warwickshire NHS Foundation Trust 10
- AINTREE UNIVERSITY HOSPITAL NHS FOUNDATION TRUST
- BARNSLEY HOSPITAL NHS FOUNDATION TRUST
- Care Quality Commission (CQC)
- DORSET COUNTY HOSPITAL NHS FOUNDATION TRUST
- EAST KENT HOSPITALS UNIVERSITY NHS FOUNDATION TRUST
- Foundation trusts
- HARROGATE AND DISTRICT NHS FOUNDATION TRUST
- Health white paper
- HULL AND EAST YORKSHIRE HOSPITALS NHS TRUST
- JAMES PAGET UNIVERSITY HOSPITALS NHS FT
- LAMBETH PCT
- LEWISHAM AND GREENWICH NHS TRUST
- LONDON NORTH WEST HEALTHCARE NHS TRUST
- MAIDSTONE AND TUNBRIDGE WELLS NHS TRUST
- MANCHESTER HEALTH AND SOCIAL CARE NHS TRUST
- Mental health
- MID CHESHIRE HOSPITALS NHS FOUNDATION TRUST
- MID YORKSHIRE HOSPITALS NHS TRUST
- National Patient Safety Agency (NPSA)
- Public health
- ROTHERHAM PCT
- ROYAL FREE LONDON FOUNDATION TRUST
- SANDWELL AND WEST BIRMINGHAM HOSPITALS NHS TRUST
- SANDWELL MH SOCIAL CARE NHS TRUST
- SHERWOOD FOREST HOSPITALS NHS FOUNDATION TRUST
- Social care
- SOUTH WARWICKSHIRE NHS FOUNDATION TRUST
- STOCKPORT NHS FOUNDATION TRUST
- TAMESIDE HOSPITAL NHS FOUNDATION TRUST
- WALSALL TEACHING PCT
- WINCHESTER AND EASTLEIGH HEALTHCARE NHS TRUST
- WORCESTERSHIRE ACUTE HOSPITALS NHS TRUST
- YORK TEACHING HOSPITAL NHS FOUNDATION TRUST