Patient Safety Watch: New data spotlights uncomfortable truth but is not enough by itself

Good afternoon, and welcome to this fortnight’s edition of the Patient Safety Watch newsletter.

Once again, we start this edition with maternity safety.

New NHSE dashboard exposes stark maternity inequalities

A new NHS England maternity inequalities dashboard – ordered by health and social care secretary Wes Streeting – has highlighted the trusts where Black women and those from the most deprived communities face significantly worse outcomes.

HSJ’s analysis of the newly published data shows that women identifying as Black and living in the “most deprived” communities experienced higher rates of pre-term birth nationally last year, almost three times as high as those of white and less deprived women at some providers.

Outlier services include Ashford and St Peter’s Hospitals Foundation Trust, where pre-term birth rates for Black and women from the most deprived backgrounds were almost three times those of white and women from the least deprived communities, and Warrington and Halton Teaching Hospitals FT, where postpartum haemorrhage rates for Black women were double those for white women.

NHS Race and Health Observatory implementation director Nandi Simpson said: “The analysis carried out by HSJ highlights the value of the disaggregated data to spotlight conditions where unwarranted variation disproportionately impacts women, babies and families from Black, Asian and other ethnic minority backgrounds. Knowledge of these inequities must catalyse action.”

My view?

Publishing disaggregated data like this is a vital step forward, but transparency alone is not enough.

The uncomfortable truth is that these disparities have been known for years. The crucial next step is moving beyond acknowledgement to urgent, structured improvement and measurable delivery of change. The next steps from the Amos review and the national maternity taskforce are crucial.

In other patient safety news…

Supreme Court: injured children entitled to ‘lost years’ earnings

The Supreme Court has ruled that children injured through NHS negligence can claim damages for the full working life they would likely have had, not just for earnings lost during their reduced life expectancy.

As reported by the Law Society Gazette, the case in question involved a girl born in 2015 at Sheffield Teaching Hospitals FT who sustained a severe hypoxic brain injury after abnormal monitoring in labour was not acted upon. The trust admitted failings.

The decision aligns the law for children with that for adults. It is also likely to add to NHS liabilities, which already total around £60bn – two-thirds of which relates to maternity claims.

In our last newsletter, we highlighted the Public Accounts Committee report examining the rapid growth in government liability for clinical negligence. With annual clinical negligence payments expected to exceed £4bn by the end of the decade, the question of how to reduce them must not focus on access to fair compensation for those harmed, but on preventing harm in the first place.

Review finds staff fear speaking up at Black Country trust

An NHSE review of Black Country Healthcare FT’s Freedom to Speak Up arrangements has found staff feared raising concerns about behaviours and sexual safety, particularly where these involved senior managers or doctors.

As HSJ reported, staff described feeling like they had a “target on their back” after speaking up, citing examples of disadvantage, exclusion and inconsistent HR processes.

Non-medical staff said concerns about medical colleagues were treated differently, describing a culture of “the medic way or no way”. The review also noted low confidence that concerns would lead to meaningful action, and a disconnect between frontline and board perceptions.

The trust said it accepted the findings in full and highlighted a 97 per cent increase in use of its Freedom to Speak Up service, alongside the recruitment of new champions, as evidence of progress.

Campaign spotlight: Action for Accreta

A new campaign, Action for Accreta, has been launched this week by Nik and Amisha Adhia.

Placenta accreta spectrum (PAS) can cause catastrophic haemorrhage if not identified before labour and is more common in women who have had previous caesareans or IVF.

Amisha, who says five hospitals failed to diagnose her condition, described fearing she was “going to die” before one consultant confirmed PAS and ensured specialist care. More than 40 families have since come forward with similar experiences of late or missed diagnosis.

The campaign, which has been covered widely in the media this week, including in The Guardian and The Independent, argues NHS guidance is outdated, data collection is inadequate, and atypical cases are being missed. It is calling for mandatory reporting, updated national guidance, improved training and every maternity unit to be PAS-ready.

Find out more at www.actionforaccreta.org

Amos review: Call for evidence reaches midpoint

Baroness Amos has confirmed that the Independent National Maternity and Neonatal Investigation has passed the halfway point of its call for evidence, with more than 6,000 responses received so far.

With four weeks remaining before the 17 March deadline, Baroness Amos urged more women and families – particularly from Black, Asian and marginalised communities, as well as fathers and non-birthing partners – to come forward. Surveys are available in seven additional languages, with interpreter support also offered. More information is available here.

The Amos review is also expected to publish a further update on its work before the end of February.

Streeting pledges valproate compensation scheme before next election

Mr Streeting has promised to introduce a compensation scheme for victims of the sodium valproate scandal before the next general election, following mounting pressure from affected families.

The 2024 Hughes Report recommended creating a compensation scheme, alongside urgent interim payments to families facing financial hardship. However, no payments have yet been made.

Speaking to ITV News, inspirational campaigners Emma Murphy and Janet Williams spoke of their feelings of being “let down” and “gaslit” by the lack of progress. Several Labour MPs have also urged the government to act swiftly, warning that the issue has been “kicked down the road for too long”.

Sharing some good stuff…

Westminster Patient Safety Symposium Blog

For those who weren’t able to attend the Westminster Patient Safety Symposium, hosted by the All-Party Parliamentary Group for Patient Safety last month, the Clinical Human Factors Group has published a great write-up of the day’s key messages. 

That’s just about all for this edition. Before signing off, this article from Health Services Safety Investigations Body chair Ted Baker is essential reading. We have included Professor Baker’s HSJ article on the same theme before, but his further thoughts on why the NHS risks slipping backwards on patient safety make essential reading.

Thanks for reading, and please look out for our next edition from Jeremy in two weeks.

James