Patient Safety Watch: The appearance of action without improving safety

Good afternoon and welcome to the latest edition of the Patient Safety Watch newsletter.

The Thirlwall Inquiry

The Thirlwall Inquiry has reported a profound failure of leadership, governance, and safeguarding at the Countess of Chester Hospital. Senior doctors repeatedly raised concerns about unexpected deaths and collapses on the neonatal unit, but those concerns were not properly investigated or escalated.

The inquiry found a “complete failure” to use safeguarding procedures, a dysfunctional relationship between clinicians and senior management, and serious weaknesses in board oversight. Parents were kept in the dark for years about concerns that their babies may have been deliberately harmed.

Lady Justice Thirlwall concluded that earlier action could have protected babies from further harm, finding that three babies might have survived and seven others could have been protected had concerns been acted on sooner.

The inquiry’s recommendations include statutory regulation of NHS managers, with an interim national barring scheme; a new national protocol for responding to suspected deliberate harm; stronger board-level monitoring of neonatal and child deaths; strengthened Care Quality Commission inspections; a new role for the National Audit Office in checking whether recommendations from major NHS inquiries are implemented; and cameras to be installed in neonatal units.

Responding to the report, health secretary Yvette Cooper said maternity and neonatal services “cannot operate on the margins” and must become a central NHS priority, backing plans to strengthen neonatal expertise among medical examiners, and confirming that the government will legislate for a statutory barring scheme for NHS managers while considering wider regulation.

As HSJ reported, NHS England has told trusts to act immediately, including installing CCTV covering neonatal storage areas by 30 November, ensuring staff and boards understand that child-death protocols apply to babies who die in hospital, and tightening insulin access and storage. NHSE is also developing plans for cot cameras so parents can remotely view babies in neonatal care.

My view

The Thirlwall report contains important recommendations – and mechanisms to increase NHS managers’ accountability are overdue – but the familiar post-inquiry prescription of more protocols, panels, regulation, and monitoring can create the appearance of action without necessarily improving patient safety.

A central recommendation is for the Department of Health and Social Care to establish a panel of independent experts to investigate suspected deliberate harm. This rightly recognises the need for rapid multidisciplinary expertise, but why create another national mechanism?

Surely the Health Services Safety Investigations Body (HSSIB) is ideally placed for this remit – yet against the advice of patient safety experts, the government is set to abolish HSSIB at the very time its independence and expertise matter more than ever.

As I wrote in HSJ, the safest NHS is one that establishes the truth fairly, supports a problem-sensing culture at every level, gives staff the psychological safety to raise concerns without fear of retribution, and investigates those concerns rigorously and early enough to protect the next patient. We must ensure that the response to the Thirlwall Report makes this more likely, not less.

In other news

HSSIB investigates placenta accreta spectrum

HSSIB has opened a new national investigation into the barriers to timely diagnosis and specialist care for women with placenta accreta spectrum (PAS), a potentially life-threatening pregnancy complication. PAS is often not identified before birth, leaving women unable to plan care at a specialist centre.

The investigation will examine how risk is recognised, how referrals happen, and where the system can improve.

An important development and a testament to the determined work of Nik and Amisha Adhia, who turned their family’s experience into Action for Accreta and have been instrumental in bringing together evidence to support the need for action.

Trust to review thousands more cancer cases after failings

County Durham and Darlington Foundation Trust will review up to 4,500 additional breast cancer cases going back to 2015 after serious failings were uncovered in its breast surgery service, the BBC, among others, has reported. 

Of the more than 500 cases reviewed so far, more than 300 involved some degree of harm, including one death, with problems including delayed diagnoses, treatment not in line with best practice, and unnecessary or excessive surgery.

The trust has apologised and acknowledged patients and external bodies, including NHSE and the CQC, had raised concerns over several years.

National alert on hoists and slings

The Medicines and Healthcare products Regulatory Agency has issued a national patient safety alert after reviewing serious falls from patient hoists and slings, which identified an average of two deaths a year since 2015.

The alert asks health and care organisations to check hoists and slings compatibility, strengthen pre-use checks, and ensure equipment is properly recorded and maintained. These are familiar risks with devastating consequences when routine safeguards fail.

Review finds oversight failures in high-risk endoscopy service

As Nursing Standard reported, an independent review has found that failures in recruitment, supervision, and governance at The Rotherham FT allowed a nurse consultant to run a high-risk endoscopic retrograde cholangiopancreatography service with insufficient oversight. 

An expert review identified care failures affecting 58 patients; 25 were believed to have suffered some degree of harm, including seven who died. The service was suspended in 2021.

The latest review recommends avoiding single-operator services and strengthening recruitment, supervision, and independent audit. The trust has apologised, adding it will not restart the service without a formal readiness review against national standards.

Martha’s Rule reaches emergency care

As reported by the BBC, Martha’s Rule is being extended into emergency departments, building on its introduction in acute inpatient services. Martha’s Rule gives patients, families, and staff a route to request an urgent review when they fear deterioration is not being addressed.

The move follows successful evaluation of the trial roll-out of Martha’s Rule in acute services and confirmation that Martha’s Rule is also going to be implemented across maternity services.

Specialist mental health services transfer to NHS trust

Northamptonshire Healthcare FT has formally taken over several secure services previously run by St Andrew’s Healthcare in Northampton, following serious safety concerns.

As HSJ reported, the transfer covers male medium and low secure services, and national specialist services for deaf men and men with acquired brain injury.

Sharing some good stuff…

Introduction to SEIPS

HSSIB has published an accessible introduction to the systems engineering initiative for patient safety (SEIPS). The video explains how people, tasks, tools, technology, and working environments interact to shape care. It is a helpful starting point for anyone investigating incidents or designing improvements.

‘Your Voice’ launched to inform National Maternity and Neonatal Action Plan

Staff working across maternity and neonatal services are being invited to take part in a three-week anonymous national conversation about what needs to change. Unlike a traditional survey, participants can contribute candidly, return to the platform, and read and respond to ideas from colleagues locally and across the NHS.

The findings will help shape the National Maternity and Neonatal Taskforce’s action plan, while participating trusts will also receive tailored reports highlighting what their own staff believe needs to happen locally.

Find out more and join Your Voice here.

That’s nearly all for this edition. Before we end, a final share: this really insightful paper on “the power and pain of words” and how language matters when responding to patients and families after harm.

The authors argue that healthcare too often uses institutional or legal language – such as “disclosure”, “root cause analysis” or “resolution” – that can feel defensive, distancing or even cause further harm. Instead, they call for more patient- and family-centred language focused on openness, learning, accountability, compassion, and reparation.

It is an important reminder that how organisations communicate after harm is not a peripheral issue; the words chosen can either help rebuild trust or deepen the damage already caused.

That’s all for this edition. Thanks for reading, and please look out for the next edition of the newsletter from Jeremy in a fortnight.

James