HSJ hosts the Patient Safety Watch newsletter, written by Patient Safety Watch chair Jeremy Hunt
While the country’s eyes are fixated on Washington DC, patient safety campaigning marches on… good afternoon and welcome to this fortnight’s edition of the Patient Safety Watch newsletter, written this time by Jeremy.
All change at the top
Several significant leadership changes have been announced at both NHS England and the Care Quality Commission.
Earlier this week, Amanda Pritchard announced she was stepping down from her role as NHSE chief executive at the end of March. I have always found Amanda to be very supportive on patient safety issues, so wish her well.
Sir Jim Mackey will be taking over as transition CEO, while Penny Dash is the government’s preferred candidate for NHSE chair. I know Jim well and he has a superb record on patient safety from his time running Northumbria Healthcare Foundation Trust. Dr Dash will also be excellent, having been writing a report on how to streamline the patient safety landscape for Wes Streeting (which we are all aching to see).
Over at the CQC, Aidan Fowler, NHSE’s national director of patient safety, is to join as interim chief inspector of healthcare and Sir Mike Richards has been confirmed as the government’s preferred candidate for the next CQC chair. I appointed Mike to be the first ever chief inspector of hospitals, which he did superbly. If anyone can get the organisation back on track, it is Mike, so this is very positive news.
In other news…
Nottingham ordered to pay £1.7m over failings in three baby death cases
In another worrying maternity scandal, Nottingham University Hospital Trust has been ordered to pay £1.7m after pleading guilty to failing to provide safe care and treatment in the cases of the deaths of three babies – Adele O’Sullivan, Kahlani Rawson, and Quinn Parker – in 2021. The £1.6m fine – which was due in addition to £67,755 in costs and a £190 victim surcharge – was reduced from £5.5m, partly to reflect the trust’s early guilty pleas.
It is the second time the CQC has prosecuted the trust for maternity failings – it was fined £800k in 2023. And Donna Ockenden’s review into Nottingham baby deaths continues, with 2,000 families now taking part.
This month has also seen deeply concerning reports from the inquest into the tragic death of baby Ida Lock, who was born at the Royal Lancaster Infirmary (part of University Hospitals of Morecambe Bay FT) in November 2019. Many will worry the trust has not learned the lessons following Bill Kirkup’s 2015 Morecambe Bay Investigation, which I commissioned.
Things have been going worryingly wrong in maternity safety since the pandemic. From 2013-2020, stillbirth rates dropped by 18.4 per cent and neonatal deaths fell by 17 per cent. But since the pandemic, the data now clearly show that maternity safety is heading in the wrong direction, including in the latest MBRRACE-UK numbers published this month. We need to turn the tanker back around again – just how will be a big focus of the all-party parliamentary group for patient safety alongside its sister APPG on baby loss.
Patient safety in the 10-Year Plan, please
As APPG chair, last week I wrote to Mr Streeting outlining the APPG’s recommendations for ensuring patient safety is at the heart of the 10-year plan for the NHS. The new APPG includes some brilliant new MPs such as Anna Dixon, Labour MP for Shipley and former DH official working on patient safety, and Rosena Allin-Khan, who is a practising emergency department doctor.
‘Dysfunctional’ admin putting off patients, research shows
Research published by National Voices, The King’s Fund, and Healthwatch England earlier this month revealed widespread problems with NHS admin. A poll found nearly two-thirds (64 per cent) of patients and carers have experienced at least one admin problem in the past year, such as missing test results, problems changing appointments or receiving wrong information. All too often, poor admin can lead to poor safety.
ICBs ‘detached’ from patient safety, warns watchdog
A report from the Health Service Safety Investigations Body has warned that the move to the new patient safety incident response framework has left integrated care boards “detached” from patient safety incidents, with some ICBs only learning of incidents when they were asked to provide a statement for the media. As Sian Blanchard, HSSIB head of patient safety insights, said: “It is crucial that lines of responsibility and accountability are defined including at a national level, and those we spoke to welcomed any further work on establishing approaches that would help them to manage recurring or emerging risks more proactively.”
A spotlight on Martha’s Rule
Moving on to some more positive stuff, check out this informative and timely blog from the Royal College of Paediatrics and Child Health on Martha’s Rule, which has already started saving lives. Well done Merope Mills, a formidable campaigner.
CHFG Charity: Help shape our future
The trustees of the Clinical Human Factors Group are seeking your input to help shape their goals for the next one to three years. They’ve launched a short questionnaire to gather feedback, which will guide their planning and be discussed at their trustee meeting on 6 March. It is a brilliant small charity set up by Martin Bromiley, which is helping to provide the secretariat for the Patient Safety APPG. Let them know what you think their focus should be, going forward.
Re-evaluating reproductive health research funding metrics
A recent briefing by the Sands and Tommy’s Joint Policy Unit challenges the notion that research into reproductive health and childbirth is overfunded relative to disease burden. The briefing critiques the use of disability-adjusted life years as a metric, arguing it inadequately captures the true impact of pregnancy loss. The authors call for a reassessment of funding allocation metrics to better reflect the significance of reproductive health issues. A thought-provoking paper!
That’s all for this edition – see you in a fortnight when James will be doing the newsletter.
Jeremy Hunt
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