Senior Lead Clinician
Welcome to the first edition of Prioritising patient safety, my new quarterly blog series.
Each month, we publish between 70 to 100 of our casework decisions as a way to share learning that will help organisations improve their service and prevent mistakes happening again.
Through this blog, I’ll be highlighting some of the cases we publish to share good practice and findings from our casework more widely. I hope this will help colleagues across the NHS use the power of complaints to improve patient safety. I’ll also provide a round-up of wider NHS patient safety developments.
In my first blog, I’m focusing on a couple of cases we’ve looked into about maternity care and imaging.
Maternity care: resolving a complaint through mediation
Despite many patient safety improvements in maternity care, the Ombudsman is still seeing and upholding complaints about care and treatment in maternity settings. Since publishing our spotlight report last year, we’ve had several more complaints brought to us.
One of these was from Pamela, who complained to us about the care and treatment she received when she went into labour with her third child.
When she went into hospital, Pamela knew from previous experience that she was in an advanced stage of labour. But the midwife did not think that she was dilated enough to be in labour and she was placed on an antenatal ward for observation. Pamela disagreed with this decision and said so. But she explained to us that English is not her first language and she felt she was not listened to.
When the midwife realised Pamela was in fact in advanced labour, she was escorted from the antenatal ward in her gown to a room with other patients and relatives.
Pamela complained to the Trust about her experience but was not happy with their response so she brought her concerns to us.
Putting things right
Sometimes when we look at a case we may decide that a full investigation is not the most appropriate way to resolve the complaint. We identified this case as suitable for mediation and both parties agreed to this. Mediation is different to our usual investigation process in that we don’t make a decision on the complaint. Instead, we facilitated a discussion between Pamela and the Trust so they could reach a decision where both parties could feel listened to.
Pamela was encouraged to share how the Trust’s actions made her feel. She explained to the lead midwife, other senior midwives and the complaint manager that she did not feel listened to. She said she felt control was taken away from her and the experience impacted her mental health.
The team from the Trust listened to what Pamela said. They acknowledged that what happened was not her fault and that she had done nothing wrong. Taking responsibility and recognising when things go wrong is something many people hope for when they bring their complaints to us.
The Trust resolved Pamela’s complaint by:
- inviting her to record a video of her story, which it shared with the Trust’s board and used in staff training
- giving her the opportunity to work with a community midwifery team who focus on working with women whose first language is not English
- offering her counselling
- rethinking its approach to maternity care and making sure parents are listened to.
This is an excellent example of patient involvement and of what an organisation can achieve when they listen to patients’ stories. Mediation gave Pamela an opportunity to have her concerns addressed directly by staff from the Trust. It meant they could better understand where things went wrong and how they could learn from what happened. This gave the Trust valuable feedback to make improvements to its maternity care.
Imaging: addressing missed opportunities in communication
Another patient safety issue we frequently see in complaints that come to us is poor communication when it comes to imaging results. We highlighted this in our Unlocking solutions in imaging report.
Ian’s family brought his case to us after he sadly died of cancer in 2024. They were concerned that delays in his diagnosis may have meant he was unable to access care and treatment.
As part of our investigation, we took clinical advice from an independent GP and found that the Trust had failed to follow up on significant findings from Ian’s ultrasound scan, including multiple hypoechoic lesions. The report that went to Ian’s GP did not explain that these lesions were significant and needed to be investigated. It did not include any advice on safety-netting and was not escalated to a radiologist.
In Ian’s case, we found it was unlikely that signposting these findings would have changed the outcome. But our investigation did reveal failings in the way radiology findings were communicated, which could impact on other patients. When we raised these issues with the Trust it responded positively and accepted this as an important learning point. As a result of our investigation, the organisation:
- updated its radiology procedures
- hosted training sessions emphasising the importance of communication
- introduced peer review audits.
It’s good to see the Trust take constructive action to make sure these mistakes don’t happen again. This reflects the organisation’s commitment to learning from feedback and improving patient safety.
Prioritising the patient’s voice
The cases we’ve highlighted show the importance of prioritising the patient’s voice, acknowledging when things go wrong and taking steps to put things right. The NHS Complaint Standards can help you do this by setting out how NHS organisations should approach complaint handling in a clear and consistent way.
What’s new in the world of patient safety
- In October 2024, the Patient Safety Commissioner launched new Patient Safety Principles. These provide a framework for decision making, planning and collaborative working with patients as partners.
- The Care Quality Commission published its annual State of Health Care report. It highlights several areas of concern around patient safety, including maternity care and people with learning disabilities.
- The Government commissioned an independent review of patient safety organisations. This was one of the recommendations we made in our 2023 Broken Trust report.
Let me know what you think
Let me know what you think of this first edition of the Prioritising patient safety blog and if there’s anything you’d like to see included – email content@ombudsman.org.uk.
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Tony is a GP with over 30 years' experience in the NHS. He still works in clinical practice alongside his role at PHSO. Tony has been at PHSO for 10 years, initially starting as a clinical adviser to now leading the clinical advice function for the Ombudsman. You can follow Tony on LinkedIn.
