Parliamentary and Health Service Ombudsman
Today is the fifth annual World Patient Safety Day. This year’s theme is Improving Diagnosis for Patient Safety. It recognises the importance that accurate, safe, and timely diagnosis can have on patients and their families.
We know that the dedication and hard work of thousands of brilliant NHS colleagues are responsible every single day for saving lives and avoiding harm through outstanding practice. We also know that the NHS isn’t always consistent and there is a need to understand how good practice can be shared. Sharing learning is a key theme in what I set out below.
Understanding patient safety
At its core, patient safety is about making sure that patients are kept safe while receiving care and treatment. This might seem straightforward, but there are a lot of factors that can contribute to this, including:
- keeping patients well prepared and well informed and making sure their voice is heard
- providing proper support for staff and creating an open culture, where they feel safe to raise concerns
- making sure the healthcare environment is fit for purpose.
The life-saving importance of accurate diagnosis
One patient safety issue we see time and again in the complaints people bring to us is diagnosis. Accurate and prompt diagnosis is critical to patient safety. Outdated or unavailable equipment, misreading of scans or serious delays in receiving a diagnosis can all jeopardise patient safety.
In our recent report Broken trust: making patient safety more than just a promise, we shared learning from some of the cases we’ve investigated where missed, delayed, or incorrect diagnoses have led to avoidable harm or even death.
In one case, doctors failed to identify a man’s pulmonary embolism, which is what happens when a blood clot blocks a blood vessel in your lungs. He was sent home without the right treatment and died of a cardiac arrest. We found that his death could have been avoided if the right diagnosis was made.
Our report Unlocking solutions in imaging also revealed repeated failings in the way X-rays and scans are reported on and followed up across NHS services, putting more lives at risk. Despite the recommendations made in these reports, complaints about poor diagnosis persist.
How can we improve diagnosis?
Diagnosis is an important part of the bigger patient safety picture. There are many ways to reduce the likelihood of diagnostic errors putting patient safety at risk, including:
- making sure clinicians have access to a complete patient history
- encouraging thorough clinical examinations
- improving access to diagnostic tests
- taking steps to measure and learn from diagnostic errors
- adopting technology-based solutions to support accurate diagnosis.
The NHS also needs to empower patients and their families to actively engage with healthcare workers and leaders to improve diagnostic processes. Our investigations indicate that this doesn’t always happen.
Sharing learning to improve patient safety
Significant progress has been made on patient safety in the NHS over the last decade, including setting out an NHS Patient Safety Strategy and establishing the Patient Safety Commissioner’s Office. We have also seen greater acknowledgement of the need to work with patients as partners, through initiatives such as Martha’s Rule.
PHSO plays a vital role in contributing to improvements in patient safety. We know that healthcare providers can be overwhelmed with numerous recommendations and frameworks from different regulators, arms-length bodies and independent inquiries. We’re working closely with different organisations across the patient safety landscape to develop clear and consistent messages about the changes we need to see.
Our casework investigations give us a unique perspective on common challenges in the delivery of safe patient care because we hear from both the organisation involved and the human stories of those affected. We see instances where care and treatment could have been improved, cases of avoidable harm and, tragically, death.
We want to make sure we share our casework findings and recommendations with the NHS in a way that enables learning. Our regularly published reports about the NHS and the increasing number of our casework decisions we’re publishing on our website help support this aim.
Alongside this, our Assistant Director of Clinical, Dr Tony Dysart, will be launching a new quarterly patient safety round-up blog in October. The blog will share insights on the themes, good practice and learning we’re seeing in the casework decisions we’ve made. Sign up for our blog alerts to get this delivered straight to your inbox.
Sharing learning will be a priority for us as we draw on our casework evidence to deliver real improvements in patient experience and play our part in contributing to better, safer patient care.
