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The Latest in the Continuing Cycle of NHS Patient Safety Inquiries

There does not seem to be a week that goes by without an NHS (National Health Service) patient safety crisis hitting the headlines and this has been the case for many years. Major public inquiry reports into patient safety and health quality failings are published. Recommendations are made, and then another crisis event follows soon afterwards spawning yet other reports, broadly saying the same thing.

The NHS has built up a huge back catalogue of inquiry reports into patient safety crisis’s, spanning decades containing a lot of deep thinking, useful analysis and valuable recommendations. Analysing present and past patient safety crisis inquiry reports is a very useful educational exercise and can help inform future policy development in the area. Some of the seemingly intractable, stubbornly persistent patient safety problems that beset the NHS, both past and present are identified and discussed. Revisiting reports and analysis can also refresh our perspective on patient safety issues and provides an information bedrock on which we can base change.

Patient safety inquiry reports also provide a momentum for change through their recommendations which the government of the day can accept or reject.

New Patient Safety Public Inquiry

The Department of Health and Social Care (DHSC) announced on 6th June 2019, a new independent inquiry, investigation into the serious incidents at Liverpool Community Health NHS Trust between 2010-2014. The Guardian newspaper report of the announcement contains some very worrying figures:

“Ministers have ordered an inquiry into evidence that an NHS trust failed to properly investigate 150 patient deaths and 17,000 incidents in which patient safety was put at risk. The investigation is the latest in a series of inquiries into the care provided by Liverpool Community Health (LCH) NHS Trust. They all found serious problems including shoddy treatment, bullying and failures of leadership.”

The investigation will be conducted through three stages which are described in the DHSC announcement. The inquiry will seek to identify individual serious patient safety incidents that were not reported or adequately investigated. Undertake a series of historical mortality reviews. At stage 3 the inquiry will fully investigate incidents identified in stages 1 and 2. The inquiry will determine the scale of patient harm and identify local and national lessons to be learnt from the events.

This will be the second into Liverpool Community Health conducted by Dr Bill Kirkup.The first Kirkup report published in 2018 found serious dysfunctionality in the trust (health care organisation):

“Demoralised staff were badly treated and sometimes bullied, and there was a failure of nursing management and HR procedures. Serious incidents causing patient harm were not reported, not investigated and lessons not learned. The result was unnecessary harm to patients. (p7)”.

Recurrent learning points

Recurrent learning points found will no doubt be the need to maintain safe staffing levels, good leadership and staff management practices. No bullying, good patient caring and not focusing inordinately on financing. Putting patients first, reflective and safe practice, improve communication skills at all levels, avoiding defensive attitudes when things go wrong and so on.

Reviewing patient safety crisis inquiry reports

We do need to develop much more of a sense of NHS patient safety history and to not always follow the seemingly innate and intractable NHS tendency to reinvent the wheel when there are already existing intelligence and solutions existing in current and past patient safety inquiry reports. Reading reports of patient safety inquiries is a practice to be encouraged and can help advance both national and global patient safety agendas.

John Tingle

John Tingle

John Tingle is a regular contributor to the Bill of Health blog. I am a Lecturer in Law, Birmingham Law School, University of Birmingham, UK; and a Visiting Professor of Law, Loyola University Chicago, School of Law. I am also a Patient Safety Specialist at ECRI Institute. I was a Visiting Scholar at Harvard Law School in November 2018 and formerly Associate Professor at Nottingham Law School, Nottingham Trent University in the UK. I have a fortnightly magazine column in the British Journal of Nursing where I focus on patient safety and the legal aspects of nursing and medicine. I have published over 500 articles and a number of leading texts in patient safety and nursing law. My current research interests are in global patient safety, policy and practice, particularly in African health care systems. My most recent publication is: "Global Patient-Safety Law Policy and Practice," edited by John Tingle, Clayton O'Neill, and Morgan Shimwell, Routledge 2018.

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