Introduction
It is ten years since the landmark Francis Inquiry into failings of care at Mid Staffordshire NHS Foundation Trust. The final report identified a system that should have picked up on appalling deficiencies in quality and safety of care, but ‘failed in its primary duty to protect patients and maintain confidence in the healthcare system’. The report also argued that a fundamental culture shift was needed, to make sure ‘the patient is put first day in and day out.’
The Francis report was a wake-up call for healthcare systems. In the decade that followed, the patient safety landscape has undergone significant change. Globally, there has been greater recognition of the importance of safety science in healthcare and a strategic approach to patient safety. In 2020, patient safety was included as one of the five priorities of G20 Health Ministers, and 2021 saw the publication of the World Health Organisation Global Patient Safety Action Plan.
The NHS developed an NHS Patient Safety Strategy in 2019, with an updated version expected this year. The strategy has a vision to save 1,000 lives and £100 million per year and has seen some concrete successes in specific areas, such as improved care of premature babies and reductions in prescribing opioids (pain-relieving medicines that have a serious risk of addiction). This year, the NHS will roll out the Patient Safety Incident Response Framework (PSIRF), marking a major change in the approach to recording and learning from patient safety incidents. There are also plans to expand the roll-out of medical examiners to provide independent scrutiny of the causes of deaths. This should provide answers for bereaved relatives and help NHS organisations to learn and improve the care of future patients.
On issues of transparency, there is now a legal duty of candour requiring organisations to be honest with families when they make mistakes. And there are freedom to speak up guardians to give staff a route to report patient safety issues in each hospital. There is greater recognition of the insights that patients, families and carers hold, with a Patient Safety Partner role set up to use these insights in managing patient safety.
Following the recommendation of the Independent Medicines and Medical Devices Safety Review, the role of Patient Safety Commissioner has been created to amplify the views of patients in relation to medicines and medical devices.
There has also been an important transition to a more widespread understanding of patient safety as a systems issue. As the NHS Patient Safety Strategy recognises, failings in care often result from systems and processes that allow errors to happen, rather than from people who lack the skills to care, or who deliberately cause harm. The national conversation around patient safety now focuses on learning, rather than seeking to blame individuals. And it recognises the huge complexity in healthcare processes, which means to understand when things go wrong, we must look at all the environmental and organisational factors that affect behaviour at work, not just the specific incident. This approach is now supported by the work of HSIB, drawing out national safety recommendations from its investigations.
It is clear there is no shortage of programmes, policies, new initiatives and roles to try to reduce instances of avoidable harm. But there is a disconnect between the increasing levels of activity and consciousness about patient safety and the level of progress we see on the frontline. The statistics about patient harm remain stark. There are an estimated 11,000 avoidable deaths every year in the NHS due to patient safety failings, with thousands more patients seriously harmed. Behind these numbers are the stories of individuals and their families and friends, whose lives have been shattered as a result of avoidable harm.
There is a well-recognised ‘implementation gap’ – the difference between what we know improves patient safety and what is done in practice. Overcoming this represents a huge challenge. The NHS is an incredibly complex and sometimes fragmented system, making it challenging to embed changes to working practices and cultures. The structural changes brought in by the 2022 Health and Care Act offer the potential for better collaboration at a regional and local level through Integrated Care Systems and place-based partnerships. But such structural change brings the risk of disruption as local leaders divert attention to building new organisations and relationships. There is also good reason to be concerned about the prospects for reducing avoidable harm when attention is focused overwhelmingly on throughput, and the people and systems that make up the NHS are under growing pressure.
We know there is a long way to go to embed working cultures that can learn and improve in response to failings in some parts of the NHS. In the latest NHS Staff Survey, nearly 40% reported they did not feel safe to speak up about anything that concerns them in their organisation. More worrying still, less than half of staff felt confident their organisation would address their concern.
In clinical safety specifically, more than a quarter of staff did not feel secure raising concerns about unsafe clinical practice and nearly 40% did not feel confident their organisation would address their concern about unsafe practices. These two measures have worsened in the last two years. This polling is a reminder of the gap between the ‘learning not blaming’ vision of national strategies and the day-to-day experience of frontline NHS professionals.
Concerns about progress in patient safety need to be considered against a backdrop of intensifying workforce pressures, creating further risks. Latest data from NHS England shows there are more than 8,000 doctor vacancies and more than 40,000 nursing vacancies across the NHS. The CQC, in its latest State of Care report, said that ‘continuing understaffing in the NHS poses a serious risk to staff and patient safety, both for routine and emergency care’.
The latest data from the British Social Attitudes Survey shows the cracks are growing. Although the British public remain committed to the founding principles of the NHS as a universal service, funded by taxation and provided free at the point of contact, public satisfaction with the service is now at just 29%. This is seven percentage points lower than the year before and the lowest level since the survey began in 1983.
The NHS cannot wait any longer. Nor can the people who use it or work in it. We must see urgent action and sustained commitment to address the root causes of problems that result in patient harm.
About this report
Recognising this challenging context, we have developed this report to share learning from our investigations into complaints about serious avoidable harm in the NHS.
Our intention is not to further demoralise NHS staff and leaders at a time of extreme pressure. We recognise that the vast majority of NHS staff are highly motivated to provide excellent care and never intend to cause harm. And we know that involvement in patient safety incidents can be traumatic for staff too.
The Ombudsman has a unique position in the patient safety landscape. We investigate impartially and do not to take sides or speak on behalf of patients or clinicians. Our role is to objectively and independently understand what happened. Where we find failings, we make recommendations for learning to improve services and protect patients. The cases we see highlight persistent clinical failings and, perhaps even more importantly, persistent failure to respond to patients and families in a compassionate way when they raise complaints.
This report builds on the detailed and extensive work of countless others over the past ten years. In recognition of that, we have engaged with policymakers, oversight bodies, regulators, professional bodies and advocacy organisations to test and refine our conclusions and recommendations.
By analysing the unique evidence of complaints we have investigated, we have identified two sets of findings. First, we reflect on common themes that emerge when clinical failings have led to avoidable harm. Despite the diversity in the cases we looked at – some involving babies a few days old, others older adult patients; situations that progressed in a matter of hours and others over a number of years – there are issues that come up repeatedly.
Second, we look at the additional harm – sometimes called compounded harm – that happens when families, who have already experienced the devastating consequences of avoidable harm, try to understand what has happened to their loved ones but are met with a poor response from NHS organisations.
In the final section, we suggest the wider changes needed to see the improvements that patients, families and clinicians deserve when it comes to serious avoidable harm.
Words we use in this report
Throughout this report, we use clinical failings to refer to clinical care and treatment that a patient should have received but did not receive.
We use avoidable harm to refer to clinical harm that a patient suffers because they did not receive the right care and treatment at the right time.
How we developed this report
To develop this report, we undertook a qualitative analysis of over 400 detailed health complaint investigations from the past three years. We identified 22 cases where someone had died and we found that the death was – more likely than not – avoidable. We know that relatively few families, having been through a local complaints process while dealing with their own grief, will feel able to keep going and bring their case to us. So these 22 cases are a significant sample of what is likely to be a much bigger problem.
In these cases, we found that the patients would not have died if they had received the right care and treatment at the right time. This happened mainly in inpatient settings in NHS acute trusts, including emergency departments, intensive care units (ICUs) and
general medical wards.
We analysed the cases in more detail to develop the themes in this report. We conducted four interviews with families who brought the cases to us, to hear from them directly about their experience of raising concerns with Trusts. We supplemented this with a review of secondary literature on patient safety to put our evidence in context.