Cascading and repeated errors threaten patient safety

25 March 2022

Patient safety is, and always should be, the guiding principle behind medical care delivered in the NHS and in private healthcare, whatever the age of the patient receiving that care. One of the promises within the Hippocratic Oath, which all medical students must take before becoming a doctor, is to “first, do no harm".

The most notorious examples of this commitment being turned on its head are the Mid Staffs scandal, where a public inquiry heard that hundreds of people died at Stafford Hospital amid ‘appalling’ levels of care because managers cut costs and reduced nursing numbers in a bid to achieve Foundation Trust status, even if that meant patients were put at risk, and the criminal malpractice of West Midlands breast surgeon Ian Paterson.

Sarah Harper, legal director in Shoosmiths medical negligence team, observes that, when problems do arise within a trust, they are usually not limited to just one service and a different approach is required:

“When one thing goes wrong with the usually high standard of patient care that the NHS provides, it could be a sign that everything is wrong. Underperformance in any area has a cascading effect throughout a hospital trust and may indicate a broader problem. A depressing common commentary running through all the reports on failures in care over the past few years has been to describe dysfunctional systems and substandard care provided by staff deficient in skills and knowledge.”

The Ockenden Report

The much anticipated report by Donna Ockenden into hundreds of baby deaths and unusually high maternal deaths at Shrewsbury and Telford NHS Trust is expected to be published by month end.

This will be the second report of the Independent Maternity Review and will build upon the work of the first report to ensure the recommended local actions for learning and immediate and essential actions are strengthened and implemented at the Trust and across the wider maternity system in England. 

Other maternity failures

However, Shrewsbury is not an isolated example.  East Kent hospitals university NHS foundation trust was prosecuted for failures in maternity care in 2021, resulting in a £773,000 fine.  East Kent Maternity Services are also subject to an independent investigation by Dr Bill Kirkup, who led the investigation into serious maternity failings at University Hospitals of Morecambe Bay NHS foundation trust, and its findings are anticipated in Autumn 2022.

The investigation of Nottingham university hospitals trust which revealed multiple missed opportunities to prevent fatalities in mothers and babies, and an inquiry, set up in 2013 by the then health secretary Jeremy Hunt, into care at  University Hospitals of Morecambe Bay NHS Foundation Trust (UHMBT)  also found that maternity services were beset by a culture of denial, collusion and incompetence.

Failures in urology services

Sarah maintains that the last example of Morecambe Bay NHS Foundation Trust proves her point, with the Trust’s urology department now being criticised shortly after the Royal College of Surgeons (RCS) made a number of urgent recommendations for improvements in the trauma and orthopaedics department. The independent investigation of the University Hospitals of Morecambe Bay NHS Foundation Trust's  urology services, published in November 2021, was carried out by Niche Health and Social Care Consulting

Their report said complicated procedures being carried out at larger sites meant de-skilling of some staff and some potentially territorial behaviour, so that only a small number of clinicians retained the more complex work.  The report also found that Internal concerns and complaints were not dealt with properly and some members of staff did not communicate with each other in an effective way, which raised issues for patient safety.

Sarah reflects:

“Depressingly, the criticisms and comments on the failings in UHMBT’s maternity service in 2013 are almost exactly the same as the criticisms and comments in the review of the Trusts’ failing urology services in 2021. The trust made some very serious mistakes, but more than that the same mistakes were repeated across several departments. If lessons are to be learned by any failing trust, those lessons should be applied across all services, not simply piecemeal in response to criticism of specific departments, to ensure the safety of every patient.”



This information is for educational purposes only and does not constitute legal advice. It is recommended that specific professional advice is sought before acting on any of the information given. © Shoosmiths LLP 2024

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