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
Contact me in confidence here. Shaun Lintern, patient safety correspondent
A worrying portent for the future
Primum non nocere – first, do no harm – is a philosophical tenet at the core of most healthcare professionals and managers’ approach to their jobs. Florence Nightingale summed it up saying that “it may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm”. Such was the power of her words that Sir Robert Francis QC reused them in 2010 in his first report on the Mid Staffordshire scandal.
Tragically, healthcare is not perfect and thousands of patients are harmed and killed every year. As many as 190 a week are reported via the National Reporting and Learning System to have suffered severe harm incidents. These are often a consequence of genuine human error and accidents that happen despite the very best intentions.
However, sometimes harm can be systemic – a result of the way organisations, clinicians and processes are designed. NHS England has found itself at the centre of a storm in the past few weeks following the avoidable deaths of two women who were denied emergency neurosurgery because of a lack of intensive care beds and poor referral practices. Coroners in both cases said the patients, Teresa Dennett and Mary Muldowney, would have survived had they received surgery sooner.
At the heart of both cases was a shortage of ICU beds, but also a failure of the system. Poor protocols on what to do and poorly communicated guidance meant clinicians in both cases were left to “broker a deal” with other trusts to try to get their patients treated. Some of the consultants involved, faced with huge pressures, made poor decisions that were process driven rather than clinical.
I was inundated with doctors and nurses telling me this kind of deal making while patients wait for treatment is common. This could become an increasingly risky area of practice as the NHS centralises more specialist care – quite rightly – to deliver better outcomes. If referral processes are poor and clinicians consider their own units first and the patient second, we could see more avoidable deaths.
In a similar way, NHS England is currently driving a national transformation that will reshape the NHS driven more by hope than evidence and realistic planning. This will deliver new regional power structures, local accountable care organisations and inevitable governance wrangles and cock-ups. The system is increasingly focused on its form, not its function; and with the underfunding of healthcare in England, many areas are making fantasy assumptions and pursuing service and workforce cuts after so much progress has been made towards safe care.
National leaders are pulling whatever levers they have, essentially playing with their own £120bn Meccano set. But we are increasingly losing sight of patients. The cases covered by HSJ could be a small portent of what might lie ahead.
Waiting more than 15 years for answers
Sticking with form over function: the treatment of Elizabeth Dixon’s parents by national NHS bodies in the past three years should be a permanent stain on their reputation. Baby Lizzie died in 2001 after being left permanently brain damaged when staff failed to treat her high blood pressure after her birth, and after being poorly cared for in the community. She suffocated to death after a poorly trained nurse failed to keep her tracheostomy tube clear. Her parents have raised multiple concerns, including fears that the circumstances of her death may have been covered up.
A joint inquiry planned in 2014 between NHS England and the CQC collapsed when Simon Stevens pulled the plug, saying NHS England was not an investigatory body. This was despite the fact that NHS England was a commissioner of care and had responsibility, at that time, for patient safety.
The CQC had no powers to press ahead but did an excellent job on a thematic review last year that identified serious risks for babies like Lizzie.
The PHSO took nine months to say it also wouldn’t consider the case.
Finally, after HSJ highlighted Lizzie’s story, Jeremy Hunt ordered an investigation. Such interventions should not be necessary. After a delay, Bill Kirkup has been appointed to lead it and I am confident he can deliver a result for the Dixon family and provide lessons for the wider NHS.
But this inquiry should never have been necessary. Families cannot rely on journalists and scandals to deliver the results. The system has to do better in being able to pick up these issues and deliver on them sooner. It’s more than 15 years since Lizzie died. No parent should have to wait that long.
Confronting today’s healthcare challenges
I am delighted to be chairing this year’s Patient Safety Congress at Manchester Central Conference Centre on 4 and 5 July. The event marks the 10th anniversary for the congress and this year I am pleased to welcome an increasing number of patients to the event to provide their unique insight and experience. We are also lucky to have experts from around the world to deliver global perspectives on safety systems.
Speakers will include the new chief investigator of HSIB, Keith Conradi; French safety expert René Amalberti; NHS Improvement chief executive Jim Mackey and many more. The agenda is packed with sessions from experts covering topics as varied as safe staffing, human factors, incident investigation, sepsis, infection control and end of life care.
We have asked all our speakers and panellists to provide key takeaway messages so that there are as many opportunities for meaningful learning as possible for delegates – who we hope to equip with ideas and tips to deliver change in their own organisations.