Patient Safety Watch: Jeremy Hunt on how we can save 13,500 lives

Good afternoon, and welcome to this fortnight’s edition of the Patient Safety Watch newsletter – our final one for the year so Merry Christmas to all our readers!

National State of Patient Safety 2024

It’s been a busy few weeks for the Patient Safety Watch team as we recently published our landmark annual review of patient safety, commissioned from Imperial College, The National State of Patient Safety 2024.

When I founded Patient Safety Watch in 2019, the aim was simple: to quantify how much progress is actually being made in tackling the scandal of avoidable harm and death. So every two years we commission the brilliant team at Imperial’s Institute of Global Health Innovation, led by Lord Darzi, to do just that. In the alternate years the institute does a global patient safety ranking (we came 21^st out of 38 Organization for Economic Cooperation and Development countries). This year’s report was sobering but perhaps not surprising: compared to 2022, patient safety has worsened in 12 out of 22 areas tracked. One of the biggest concerns is maternity services, where rates of women dying during or shortly after pregnancy, and babies dying within 28 days of being born, have increased for the first time in a decade.

It has not been a good couple of years for patient safety as the NHS recovers from the pandemic. But the potential for improvement is huge: if the UK matched the top 10 per cent of OECD countries for treatable mortality (the closest proxy to patient safety) an astonishing 13,495 lives would be saved annually. That is 37 lives every single day! Nor is this figure a theoretical state of perfection: it is what is being achieved in countries like Australia and Switzerland today.

Martha’s Rule already proving safety benefits

Yet progress is being made. At the report launch event, we heard from Merope Mills, mother of Martha Mills, an amazing campaigner whose work in Martha’s name has led to the introduction of Martha’s Rule in England (giving patients and their loved ones the right to a second medical opinion).

Merope finished her talk with the following words: “As I know too well, losing a loved one when it’s a preventable death compounds your grief and devastation. When nobody learns from it, and nothing changes, it just makes you feel like their life meant absolutely nothing to those who let them down. For that reason above all others, we must work towards a reversal of these trends and deliver real progress towards reducing the devastating impact of healthcare harm in the UK today.”

As reported widely in the news this week, early data from the trial of Martha’s Rule has shown hugely positive results in the 143 hospitals that have signed up so far.

In the first two months of the initiative, 573 calls raising concerns about a patient’s deteriorating condition were made. Of these, 286 required a clinical review, 57 led to a change in the patient’s care and 14 calls led to admission to an intensive care unit.

If 14 people have been referred to ICU who would not otherwise have been in just two months of calls, we can safely say this is saving lives. That’s not just Merope’s view, it is the view of NHS England medical director Sir Stephen Powis.

But still much work to do…

Reading this interview with bereaved parents Alex and Tum Nguyen shows how far we still have to go.

Alex and Tum lost their six-day-old son, Hayden, at Chelsea and Westminster Hospital in 2016 (when I was health sec) after medical staff failed to respond to clear signs of distress. As in so many similar tragic stories I’ve sadly become familiar with over the years, Alex and Tum have faced an appalling battle for the truth that they should never have had to face.

A 2017 inquest ruled baby Hayden died from natural causes, but the Nguyens pursued a seven-year legal fight to uncover the truth. A second inquest, which concluded earlier this month, found significant failings in Hayden’s care and concluded he could have survived with proper medical attention.

Speaking to the Times about their battle, Hayden’s parents said: “It wasn’t a choice for us… because it was too difficult to live without the truth being on the record. Hayden had a very short life, but it felt like they were trying to pretend he had never lived at all.”

When something as tragic as the avoidable death of a baby occurs, the system should wrap its arms around the parents, doing everything possible to provide honest answers and support them in grieving and healing as best as might be possible. Instead, the Nguyens faced a system that compounded their harm, made their grief so much harder and deflected opportunities to learn. It reminded me of the way the system shut out Scott and Sue Morrish when they lost their son Sam to sepsis.

Sadly, Chelsea and Westminster has been in the news again recently following the inquest into the January 2022 death of baby Elton Deutekom. In this case, the coroner issued a prevention of future deaths report, which raised concerns the trust had not appropriately referred the neonatal death to a coroner and may not be complying with the duty of candour to disclose evidence relevant to death to the coroner as required. The trust has told the press that it has “taken learnings from this review”. 

I set up a system called Learning from Deaths to try to tackle these issues but currently only one-third of trusts collect the data they are required to. Something for the newly established All-Party Parliamentary Group for Patient Safety to look into.

Prioritise safety over A&E targets, Streeting tells NHS leaders

Speaking on a webinar about winter pressures, health and social care secretary Wes Streeting urged NHS leaders to “prioritise patient safety” by focusing on issues like ambulance response times, handover delays, and long accident and emergency waits.

In particular, he urged emergency departments to not focus on those who could be seen and discharged quickly – an approach which helps trusts in reaching the four-hour A&E target – ahead of those who had greater clinical need.

This is absolutely spot on – but we will need a wider dismantling of centralised targets if we are to really change the culture in the NHS.

Meanwhile, the Royal College of Emergency Medicine has spoken out against NHSE’s September guidance on so-called corridor care, stating that it thought it is “not possible to provide safe and good quality care in temporary escalation spaces, such as corridors”.

RCEM president Adrian Boyle said: “While we understand why this guidance has been issued, as a college we are concerned that it represents a normalisation of what is an unacceptable and dangerous situation.”

Young people’s wellbeing at risk from move to adult services, warns report

A Health Services Safety Investigations Body report has warned the practice of moving young people from inpatient children’s mental health services to inpatient adult mental health services purely based on their age, and not on their need, is presenting various challenges. This includes being transferred to settings which are not suitable for their needs, such as a B & B, while the move itself could be a source of anxiety.

HSSIB senior safety investigator Craig Hadley said: “The report acknowledges that the delivery of mental health care is complex and services are routinely experiencing high demand. However, an inconsistent approach to transitions, compounded by a lack of integration between health, social care and education, puts the safety and wellbeing of vulnerable young people at risk.”

Staffing shortages and ‘toxic’ culture led to harm to mothers and babies, finds investigation

BBC News has reported that a whistleblowing investigation has revealed mothers and babies came to harm at the obstetrics triage and assessment unit at Edinburgh Royal Infirmary because of staff shortages and a “toxic” culture.

The report said: “There is no dispute that there have been safety concerns, near misses and actual adverse outcomes for women and babies.”

NHS Lothian said it had an “improvement plan” in place to address patient safety and the working environment as a result of the report.

Worth a read over Christmas

A recent study published in Frontiers in Health Services examines the compounded harm experienced by patients and their families following safety incidents in healthcare settings – a timely topic and well worth a read.

The work identifies a range of ways patients and their families experienced compounded harm because of incident responses. The authors advocate for more humanising processes post-incident, emphasising the need for open communication, empathy, and comprehensive support to mitigate compounded harm and promote healing.

A highly relevant paper given some of the items covered in these newsletters and also shows why initiatives like the Harmed Patient Pathway, which this newsletter has covered previously, matter.

That’s all for this newsletter, which will be the last one from us until James Titcombe returns with a new year missive on 10 January.

Season’s greetings to everyone and thank you to all our readers for your brilliant support in keeping the flame of patient safety flying. A big thank you to James who runs Patient Safety Watch and helps me write this newsletter. Finally, for those families missing a loved one this Christmas, a reminder to take care, be gentle on yourselves and reach out for help and support if you need it.

Jeremy Hunt