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Patient Safety Watch: ‘On a knife edge’

Published on: 14 Apr 2023

HSJ is now hosting the Patient Safety Watch newsletter, written by Patient Safety Watch trustee James Titcombe.

Good afternoon and welcome to this fortnight’s Patient Safety Watch newsletter.

Junior doctors’ strike places patient care ‘on a knife edge’

As this newsletter was being put together, junior doctors across the country were partway through a four-day strike, which started hours after the four-day Easter bank holiday weekend. While consultants covered shifts for much of the three-day junior doctors’ strike in March, one health leader warned NHS Confederation things would be different this time as “[consultants] have built time in lieu, additionally [the April] strike falls over Easter, when a lot of consultants had booked annual leave”.

NHS Confederation’s director of policy Layla McCay said: “Health leaders are bracing themselves for the most significant strikes in a decade with many aspects of patient care resting on a knife edge… They are deeply concerned about not being able to provide safe care as they cannot rely on the same staffing levels as they have done with previous strikes.”

As could be expected, social media is alive with heated commentary around the strike action – some are accusing government of “playing politics with patients’ lives”, while others are labelling striking doctors “deeply irresponsible”. In the middle, there is a very real impact on patient care and safety. In the short-term, there can be no doubt strike action increases patient safety risks, but, in the longer term, having a whole profession feeling undervalued and demoralised is itself an inherent risk to safe care.

People will have different opinions as to the rights and wrongs of the dispute, but one thing everyone can agree is that meaningful talks are the only chance of resolution. As with so many areas of patient safety, egos and entrenched positions won’t take us forward – what we need now is meaningful listening, kindness and humility.

NHS spent more than £1m a week on legal cases with bereaved families

The Times has revealed the NHS spent £64m last year – the equivalent of more than £1m a week – on legal costs for successful claims brought by bereaved families. It also paid out around £100m in compensation, while, of the 832 successful claims against the health service in 2021-22, the most common reason was a failure to treat or a delay to treatment. 

The report also highlights the impact the system can have on families. Joanne Hughes, who lost her daughter Jasmine following failures in her care in 2011, told The Times: “Rather than being viewed as a woman who’s just lost her child, in need of their care, in need of their help… to process what’s happened to us and to have any hope of being able to move forward, I was positioned as a potential risk or threat and treated that way.”

Ombudsman exposes several incidents of poor maternity care

report by the Parliamentary and Health Service Ombudsman has warned some women still face poor maternity care which compromises the safety of either them or their unborn child. The report highlighted examples of failures to progress labour safely, and failures to offer support and proper aftercare following a miscarriage.

”Women should be able to have confidence that they will receive safe, effective, compassionate maternity care that focuses on their individual needs,” the report read. “That is the experience of many people. But too many families still face care that puts the safety and wellbeing of women and babies at risk.”

Doulas under scrutiny

In a blog post last week, the Healthcare Safety Investigation Branch highlighted concerning cases relating to doula involvement in some of its maternity investigations. While it acknowledged the “positive and beneficial” care doulas provided in many cases, it added there were instances where “doulas worked outside of the defined boundaries of their role” and where the “care or advice provided… was considered to have potentially had an influence on the poor outcome for the baby”. 

In one case: “A mother planning a homebirth was in early labour at home. The baby was moving less than usual. The doula reassured the mother that a change in the baby’s movement pattern was normal in labour as the baby has ‘less room to move’. When the mother attended the hospital later the following day, the baby had died.”

In another instance: “A doula attended a homebirth to support a mother. The midwifery team reported… being ‘excluded from the birth team’ by the doula. The doula encouraged and supported the mother to stay at home, which was in direct conflict with the advice from the midwifery team to urgently transfer to the hospital. The significant delay in transfer to hospital contributed to the baby having a severe brain injury.”

HSIB said it will be supporting actions to introduce new national guidance for health professionals, doulas and mothers.

Three-year plan for maternity and neonatal care revealed

NHS England has published its three-year plan for maternity and neonatal services, which stated one of its four key themes as “developing and sustaining a culture of safety, learning, and support”. The report highlighted how previous investigations into maternity safety failings – including Bill Kirkup’s recent work at East Kent Hospitals University Foundation Trust – had identified weaknesses in culture, including a lack of teamworking, compassion and listening. It added it planned to introduce national leadership programmes in 2024 to help develop better cultures in maternity services while the rollout of the patient safety incident response framework this year would “support learning and a compassionate response to families following any incidents”.

The clarity and direction of the new plan has been widely welcomed, but concerns have been raised the changes called for will not happen without necessary funding. Royal College of Obstetricians and Gynaecologists president Ranee Thakar warned: “Maternity services are in dire need of investment. Without it, we are concerned that an already overstretched NHS will not be able to implement this plan. This will be another missed opportunity to ensure compassionate, personalised and safe maternity care for everyone.”

Maternity investigation programme to be hosted by CQC

Back in January 2022, the Department of Health and Social Care confirmed the maternity investigation programme currently undertaken by HSIB would be transferred to a new special health authority, set to be established by October 2023. However, in a move that took many by surprise, last month the Department announced the Care Quality Commission will now host the maternity investigation programme.

The programme’s continuation is welcome, but the move raises some questions around its future independence and the relationship between maternity investigations – intended for the purposes of learning – and CQC’s role as system regulator.

Eyes will be on the CQC to see how these concerns will be addressed.

Safety alert issued after overprescribing concerns

Six health bodies have issued a joint safety alert, warning women are being prescribed doses of hormone replacement therapy above clinical guidelines and exceeding product licences. Among the bodies issuing the safety alert were RCOG, the Royal College of GPs, and the Faculty of Sexual and Reproductive Healthcare.

Concerns about patient safety at trust with ‘corrosive’ culture

Since the last Patient Safety Watch newsletter, Mike Bewick’s long-awaited review into patient safety concerns at University Hospitals Birmingham Foundation Trust has been published. This revealed concerns about the trust’s “overzealous and coercive” management, “long-standing bullying” and “toxic” working environments.

In an interview with HSJ, Professor Bewick said, although his view was the trust was a “safe” place for patients, his team had been “disturbed” by consistent reporting of a bullying culture. He added he is “optimistic” about the new leadership at the trust.

Sharing some good stuff…

Getting the best out of SEIPS 

The Clinical Human Factors Group is responding to increased interest in the patient safety incident response framework, which encourages investigations across the NHS to use systems engineering initiative for patient safety. From June, sector-specific virtual masterclass sessions will be rolled out, starting with applying SEIPS in maternity services, emergency departments and mental health. The CHFG will consider running sector specific classes if requested.

Programme manager Dawn Benson will lead the two-and-a-half hour sessions to guide users through the background of SEIPS and how it can be applied to investigate incidents across health and social care. Dr Benson, who will be joined by clinical experts from each specialist area, will share her experience of teaching and using SEIPS as a HSIB national investigator, and as an academic at the Patient Safety Academy in Oxford. 

Places for June can be booked at CHFG Events | CHFG - Clinical Human Factors Group. Contact or for more information.

The hardest question

Finally for this edition, I’d like to signpost readers to this beautifully written and powerful blog by a colleague and friend, Susanna Stanford. Susanna will be well known to many in the patient safety community for her brilliant work in many areas, but this blog reflects on her very personal experience caring for her son, Tarka. The blog provides insights into the experience of long covid and the serious issues Susanna has faced in trying to obtain appropriate treatment and support for her son. Shared with Susanna’s permission, I’m sure it will provide an invaluable opportunity for reflection and learning.

That’s all for this edition. It remains a hugely challenging time for everyone working in the healthcare system and thanks to everyone who is working hard to make a difference.

Look out for our next newsletter in two weeks’ time, which will include a guest blog as well as the usual patient safety news roundup. In the meantime, thanks for reading and please stay safe.