Date of article: 29/06/2023
Daily News of: 30/06/2023
Country: 
United Kingdom
Author:
Article language: en
The National Health Service is suffering from a deficit of accountability and compassion for patients and their families when things go wrong, England’s Health Ombudsman has warned.
In a new report, ‘Broken trust: making patient safety more than just a promise’, the Ombudsman has said the NHS must do more to accept accountability and learn from mistakes, particularly when there is serious harm or, worse, loss of life.
When concerns are raised after such incidents they are too often met with a defensive attitude. This makes things even worse for a grieving family trying to get answers. It also places unnecessary pressures on staff, creating a barrier to learning and a gateway to making the same mistakes.
Despite significant progress made on patient safety in the last decade, ten years on from the Francis inquiry into failings in care in Mid-Staffordshire, we are still seeing too many preventable tragedies. The Parliamentary and Health Service Ombudsman (PHSO) considered over 400 serious health complaints from the last 3 years and found 22 cases of avoidable death.
The Ombudsman has called for urgent action from the Government to prioritise patient safety and protect families who search for understanding in the wake of a tragedy.
The report sets out recommendations to improve patient safety. These include:
- better support for families affected by harm
- embedding cultures that promote honesty and learning from mistakes
- getting the right oversight and regulatory structures to prioritise patient safety
- and an evidence-based and long-term workforce strategy that has cross-party support.
Ombudsman Rob Behrens said:
“Mistakes are inevitable. But whenever my office rules that a patient died in avoidable circumstances, it means that incident was not adequately investigated or acknowledged by the Trust.
“Every time an NHS scandal hits the front pages, leaders promise never again. But the NHS seems unable to learn from its mistakes and we see the same repeated failings time and time again. Our report looks at the reasons for the continued failures to accept mistakes and take accountability for turning learning into action. We need to see significant improvements in culture and leadership. However, the NHS itself can only go so far in improving patient safety. One of the biggest threats to saving lives is a healthcare system at breaking point.
“The Government says patient safety is a priority but, if it means this, the NHS must be given the workforce capacity it needs. We need to see concerted and sustained action from Government to support NHS leaders to prioritise the safety of patients. Patient safety must be at the very top of the agenda.”
Avoidable deaths
The report examines cases investigated by PHSO where patients died due to avoidable errors. Often these incidents were caused by issues such as:
- failing to make the right diagnosis
- treatment delays
- poor handovers between clinicians
- failing to listen to the concerns of patients and their families.
In every case we looked at the NHS had failed to properly investigate what had gone wrong.
In one case, doctors at Bradford Teaching Hospitals NHS Foundation Trust failed to identify a man’s pulmonary embolism.
Christopher Walmsley, 44, was diagnosed with pneumonia despite there being no evidence of this and showing symptoms of a pulmonary embolism. He was sent home without the right treatment and died of a cardiac arrest.
The Trust’s own investigation did not find that failures in Christopher’s care led to his death, however the Ombudsman found his death could have been avoided if the right diagnosis had been made.
His mother, Patricia Walmsley, said:
“He died in his bedroom, and I had to hear it. My grandson was in the room with me, and he heard him die too. It’s not something that you would wish anyone to go through.
“When we received the Trust’s letter in response to the PHSO investigation, we felt a lot better because it was official that they hadn’t done everything that they could have. We were glad we had that vindication.
“I just looked up and said, ‘my son, we’ve done the best for you that we can’. Wherever he is, he knows that we didn’t just let it drop. It won’t bring him back, but it might stop somebody else from going through the same thing.”
In another case, a woman with a history of self-harm and suicide attempts killed herself after staff at Wotton Lawn mental health unit failed to observe her as frequently and closely as they should. However, the Trust’s own serious incident investigation found that their actions did not cause harm to the woman.
The woman, who had schizophrenia and emotionally unstable personality disorder, was a long-term patient and had been prevented from self-harm twice in the three days before she died.
However, following these incidents staff at Gloucester Health and Care NHS Foundation Trust failed to update her risk assessment to include actions to reduce risks and avoid further harm.
A day after the second self-harm incident, the woman was found unresponsive. She never regained consciousness and died 18 days later.
The report also includes the case of a baby who died after antibiotics were not given quickly enough. We found that University Hospitals Bristol and Weston NHS Foundation Trust had not properly equipped its staff to acknowledge what had gone wrong.
Important details about the sequence of events and the nature of the infection were not given to the parents until seven weeks after their son died.
Staff even discussed deleting a recording made during a meeting when the parents temporarily stepped out of the room, because they realised what they had said might get the Trust into difficulty.
This complete failure of transparency created understandable mistrust and worsened the pain and distress of the family in their grief.
View the report.
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