Potentially fatal ‘never’ errors double in year on NHS


Potentially fatal “never” errors double in year on NHS; The number of patients to suffer blunders so serious that they should never occur has doubled in just one year, new figures reveal.

Report in Telegraph by Laura Donnelly, Health Correspondent. 6:44PM BST 02 Sep 2013

The number of reported “never events”, which include operations on the wrong side of the body and medical instruments left inside the body after surgery, rose from 163 to 299 in just twelve months, the official statistics show.

From October (2013), NHS trusts will be ordered to publish quarterly lists detailing the number and type of all such errors, so that performance of different hospitals can be compared.

Can you imagine the horror of one of these types of events happening to you or your family?

Why, you ask, why? In these days of ultra-caution, health and safety, risk assessments, and learning from previous mistakes, that simply because standard procedures were not followed, so many NHS patients suffered so called “never events”. (Worst of all, is the story of a search for a 7” pair of forceps which started with an MRI scan, didn’t someone suggest an X Ray?). Why, you ask again, is it that, according to the official statistics, the “never event” figures rose from 163 to 299 in just twelve months?

It’s all very comforting to hear Mike Durkin, NHS England’s director of patient safety telling the Health Service Journal that quarterly reports will be published for each hospital from October as part of a “wider commitment to transparency but also to stimulate more learning and preventative action in the NHS.”

And it’s all very well Andy Burnham, shadow health secretary, saying “These worrying figures reveal an NHS cutting too many corners and sailing dangerously close to the wind”. BUT … “Ministers have been repeatedly warned that too many hospitals in England do not have enough staff to provide care. Their failure to act has left wards understaffed and nurses overstretched.”

  • Who is blaming whom here?
  • Which Minister infact is responsible for the chronic shortage of nurses (and doctors, and physiotherapists and pharmacists and radiographers and occupational therapists and so on)?
  • Which Minister is responsible for ensuring that sufficient numbers of new UK doctors and nurses are trained to meet the rising needs of an expanding population? And finally
  • Which Minister has any clinical training at all? Far too few I fear.

 

As is usual on these pages we discuss our suggested solutions but welcome your comments too.

ReMEDI Rx’s view is twofold; in the short term, we would employ doctors and other clinical staff from abroad but test (and train if training is needed), their qualifications, their English language skills and their communications skills.  For the longer term, the sensible route is to train sufficient numbers of UK staff to safely care for the numbers of patients that have to be treated.

With doctor training for instance, the GMC registers 13,000 doctors per year but the UK only trains 6,000, turning away bright kids with handfuls of A levels. Perhaps if we trained the full 13,000, (albeit at a quarter of a million pounds a time) half the battle would have been won.

The other half of the battle will be won when safe staffing levels have been achieved with nursing. It has been established that when one nurse has 8 or more patients to care for, the situation is “unsafe”. So it would seem that 7 or less than 7 must be the worst case scenario but shouldn’t discussions be taking place at ward level (and between the clinical teams), so ensure that unplanned incidences are safely covered. Should the preferred ratio be 5 or 4 patients per nurse or less?

Sue Thornton
MD ReMEDI Rx