an ambulance parked at the entrance of an emergency department

Patient Safety and Health Quality in the NHS (National Health Service) in England: A Zip Code Lottery?

By John Tingle

The independent regulator of health and social care in England, the Care Quality Commission (CQC) regularly produces detailed inspection reports on the health and care organisations that it regulates. These reports show that quality of care and patient safety are not consistent across England’s health and care facilities. Wide variations in quality and safety between core services in the same NHS hospital or in the same locality as well as regionally are sometimes revealed. It is clear from reading the reports that patient safety and health quality cannot be a measured as a constant across England.

Two recent CQC inspection reports

Two recently published CQC inspection reports of hospital, Accident and Emergency (Emergency Room) services in different parts of England will be discussed. Both reports provide good examples of patient safety and health quality major variance. A variance which is shocking given the importance of the Accident and Emergency core services to the local community.

Pilgrim Hospital, Boston, Lincolnshire: Emergency Department

The CQC between December 2012 and July 2019 have inspected urgent and emergency care services at Pilgrim Hospital, Boston, ten times. The CQC have previously taken urgent enforcement action. The report makes for uncomfortable reading as it shows a litany of care failings.

The department was too small for the number of patients arriving. Patients who self-presented were triaged in line with national guidance though some continued to wait a considerable time before being clinically assessed and treated. The longest wait in the department was 20 hours and 20 minutes as at 10am on 7th January 2020.

The report states that the resuscitation area operated at full capacity for the duration of the inspection. The CQC inspectors noted one case in which a patient was held on an ambulance for over an hour despite the paramedic twice raising their concerns about the patients deteriorating condition. Staff caring for the patient were clearly distressed because of the delay.

Management of neutropenic septic patients remains an area which requires significant improvement. Staff also were not following revised guidance on completing an ECG within ten minutes for all patients presenting with chest pain. The report found that some staff did not treat patients with compassion and kindness and did not respect their privacy and dignity. The report states concern over the management of patients with diabetes.

There was also a shortage of permanent nursing, medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care and treatment.

It is a useful exercise to contrast this report with the North Middlesex University Hospital quality report which also involved an Accident and Emergency (Emergency Room) inspection and can be seen to be in marked contrast to the Pilgrim Hospital inspection report.

North Middlesex University Hospital Haringey, London: Emergency Department

The CQC inspectors found that the design, maintenance and use of facilities premises and equipment kept people safe. Staff were trained to use them. In terms of assessing and responding to risk this was found to be positive. The department had a safe and working triage system.  High level findings included that despite there being a relatively high vacancy rate within specific bands,there were enough nursing and medical staff with the right qualifications, skills, training and experience to keep patients safe from avoidable harm and to provide the right care. The report states that the service had managers at most levels with the right skills and abilities to run a service which provided high quality, sustainable care.


It is clear from reading CQC inspection reports that NHS safety and quality in health care can be extremely variable. Some hospitals are simply better than others at delivering safe and quality care. Some of the reasons why can be seen in CQC inspection reports.

A major issue is the extent to which the NHS and the general public will continue to allow, tolerate significant variations of quality and safety in hospitals and other health services?In a resource constrained NHS health care environment there are major challenges with accident and emergency care.The services are over burdened and operating currently at full stretch and even more.Perhaps in any industry it is inevitable that there are going to be outlier services.That however is not a reason to expose patients to unsafe care, an inevitability argument should not be used to tolerate unsafe health care.

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 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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