This week, there were also reports of over 600 blunders, or 'never events', having occurred in NHS hospitals in the 16 months leading up to July 2019. A 'never event' is an occurrence so serious, it should never happen. Examples include doctors operating on or amputating the wrong body parts, doctors undertaking procedures intended for someone else, patients receiving transfusions of the wrong blood type or being given overdoses of drugs. There were reportedly over 100 cases of surgical tools, such as gloves, chest drains and drill bits, being left inside patients following operations.
Each of these 'never events' will have resulted in a significant and lasting physical and mental impact on the patient and their family. There will also have been an impact on the surgeons and healthcare staff involved, given that these are people who have committed their lives to caring for other people. It should be noted that the NHS cares for over 1 million patients every 36 hours, so these occurrences are rare. Nevertheless, they are entirely avoidable and measures need to be put in place, and utilised, to prevent them from occurring in the first place.
Whilst legal action is available to those who have received negligent treatment, the remedy it provides is in no way a perfect solution. In my experience, no amount of money will compensate for the physical pain, emotional trauma and lost time which results from negligence.
The high numbers of 'never events' are a symptom of a much larger problem, being the pressure our NHS is under due to lack of funds, staffing shortages and an aging population.
Since April, NHS England and NHS Improvement have worked together as a new single organisation to better support the NHS and deliver improved care for patients. Dr Aidan Fowler, NHS National Director of Patient Safety, wants to fundamentally change the system. Rather than point the finger at individuals, he believes the NHS should move away from a blame culture where the focus is on individual error. Dr Fowler has said that blame relies on two myths:-
"First, the perfection myth: that if we try hard, we will not make any errors. Second, the punishment myth: if we punish people when they make errors, they will not make them again."
He considers blame culture results in wider problems being missed and mistakes being repeated. Instead, following consultation, a strategy has been developed with the aim of creating a 'just culture' where individuals feel safe to admit errors and learn from them. In an effort to encourage the reporting of concerns, each hospital is to have a dedicated expert who deals with concerns raised by all staff - from the cleaners to the consultants. All staff are to be trained to act if they spot risks. There are also plans in place to reduce drug errors by greater use of technology, prevent falls by increasing efforts to identify and support frail patients and lower mortality rates in maternity wards by improving risk assessments and surveillance.
It is heartening to find that, on digging a little deeper below the sensational headlines, work is being done to address the root causes of the issues within the system to try to improve it for the benefit of both staff and patients, and protect our NHS for future generations".