NHS building

NHS Patient Safety in the ‘New Normal’

By John Tingle

National Health Service (NHS) patient safety reports, which show common errors being made, are beginning to appear in the “new normal,” after the worst of the COVID-19 pandemic has passed in the U.K.

For example, in June, NHS Improvement released data on Never Events reported as occurring between April 1 and April 30, 2020. The report has a caveat in that the data covers the COVID-19 crisis period. During this time, NHS services were refocused on COVID-19, and not on services such as planned and elective surgery. The report states that there were 15 serious incidents that appeared to meet the definition of a Never Event in the Never Events list 2018 and had an incident date between April 1 and April 30, 2020.

Recently, the Shrewsbury and Telford maternity care crisis has also developed. The crisis involves hundreds of parents who have only recently learned that their child’s death, or other injury, including brain damage, may have been caused by an avoidable mistake.

Matthew Weaver writes in the Guardian newspaper that West Mercia Police  have confirmed that they are looking into Shrewsbury and Telford NHS Hospital Trust, which ”threatens to be one of the worst scandals in the history of the NHS.” Weaver continues, “The trust’s maternity services are currently subject to an independent inquiry, led by Donna Ockenden, which has identified 1,170 cases over a 40-year period that warrant investigation.“

And the Care Quality Commission (CQC), the independent regulator of health and social care in England, has just published a report on in-patient satisfaction.

The annual adult in-patient survey has been conducted annually since 2004. The survey asks people who were adult in-patients in hospital for at least one night during July 2019 about the care they received. They were asked about matters around such issues as person-centered care, experience of admission to hospital, meeting fundamental needs, availability of staff.

The annual adult in-patient survey 2019 is very much a swings and roundabouts report, containing several positive and negative findings in different areas. There are clear patient safety lessons to be learned from this report, as many of the same problems are seen repeatedly, year after year. Problems associated with patient discharge from hospital were recurrent.

In response to a question about whether patients felt like they received enough emotional support from hospital staff, during their stay, 53% replied, “yes, always,” while 17% said they did not. And only 36% responded, “yes, definitely,” when asked if they found someone on the hospital staff to talk about their worries and fears. When asked about whether questions were answered in a way that they could understand, 80% of patients who had an operation during their stay replied, “yes, completely.”


The NHS can be seen to be making reasonable, incremental progress towards developing an ingrained patient safety culture. But reports, including the developing maternity crisis at Shropshire and Telford Hospitals Trust, show the urgent need for the NHS to learn from past adverse patient safety incidents, as many of the patient safety problems detailed in these reports occur repeatedly.

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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