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Hunt calls for action on NHS 'scandal of errors'

Around 3,000 patients died needlessly last year as a result of poor care, Jeremy Hunt will say in a speech as he calls on the health service to tackle the “silent scandal of errors”.

The health secretary will confirm that nearly 500,000 people were also harmed unnecessarily while the NHS also recorded 326 “never events” - incidents so unacceptable that they should never happen - in just 12 months.

In a speech at University College London Hospitals, Mr Hunt will suggest the UK has become “so numbed to the inevitability of patient harm that we accept the unacceptable” and call for a change in culture that means errors and injuries from care are constantly revealed and reduced.

Mr Hunt is expected to say: “We have allowed ourselves to settle for levels of patient harm that are simply unacceptable. The facts are clear - last year there were nearly half a million incidents that led to patients being harmed, and 3,000 people lost their lives while in the care of the NHS.

“I pay tribute to the many NHS leaders who have refused to accept any level of patient harm as satisfactory or inevitable and are fighting hard to turn the tide. We must make sure this reflected across the NHS. It is time for a major rethink - a different kind of culture and leadership, where staff are supported to do what their instincts and commitment to patients tell them.

“We must make sure that patients know where the buck stops and who is ultimately responsible for their care. And above all, we must listen more to NHS staff, so we can design systems that encourage them to act safely whatever pressures they face.

“I want the NHS to be the world’s safest health system. It has all of the tools to do this, and I believe it should aspire to nothing less.”

It comes after revelations that the health watchdog’s cover-up over a failure to investigate a series of deaths stretched all the way to the top of the organisation.

The Care Quality Commission’s former chief executive, Cynthia Bower, was present during a discussion of the deletion of an internal review which criticised the regulator’s inspections of University Hospitals of Morecambe Bay Foundation Trust, where a number of mothers and babies died, according to an independent review.

Mr Hunt will add: “In the wake of Mid Staffs, Morecambe Bay and many other shocking lapses in care, we must ask ourselves whether we, along with other countries, have become so numbed to the inevitability of patient harm that we accept the unacceptable.

“That grim fatalism about the statistics has blunted the anger that we should feel about every single individual we let down, anger that should be the fuel of an uncompromising determination to put things right.”

Health officials said the NHS tops the International Commonwealth Fund comparison on patient safety, beating France, Germany, Sweden, Norway and the US.

The health service sees nearly three million people every week and around 0.4% of those appointments ended up with incidents of harm while 0.003% ended with a person’s death.

“This is a tiny proportion of the total number of people treated,” Mr Hunt will say. “But even those figures amount to nearly half a million people harmed unnecessarily every year.

“And 3,000 people who lost their lives last year - not despite our best efforts, but because of failures in our efforts. That’s more than eight patients dying needlessly every single day in our wards and operating theatres.”

International studies suggest there is likely to be significant under-reporting of “never events”, according to officials.

Of those recorded in 2011/12, 70 patients were given “wrong site” surgery, where the wrong part of the body or even the wrong patient was operated on, and 41 people were given incorrect implants or prostheses.

Mr Hunt will call for the NHS to become the first healthcare system in the world to publish information on the likelihood of a harm-free patient experience across every hospital in the country.

The health secretary will also set out proposals that mean the return of days when the name of the responsible doctor and responsible nurse were clearly written above every bed in every hospital, so patients know “where the buck stops”.

Norman Williams, president of the Royal College of Surgeons, said: “We are clear: any preventable harm to patients is unacceptable. However rare these incidents are, never should mean never and avoiding such errors should be the priority of every surgeon.

“The Royal College of Surgeons, alongside NHS England, is currently running a ‘never events’ in surgery survey to find out what can be done better and to help us put an end to such errors.

“The return to having the name of the responsible doctor and responsible nurse above every bed is welcomed - it is only right and proper that every patient knows who is accountable for their care.

“The surgeon is the advocate for the patient and this relationship is built on trust. We must do all we can to continue to deserve this trust by ensuring any problems are raised and addressed early.”

Sir Richard Thompson, president of the Royal College of Physicians, said: “The health secretary is right to focus on creating a supportive and transparent culture in the NHS. Robert Francis called for a fundamental culture change in NHS so that patients are the first priority of all that the NHS does.

“The RCP believes that more and better clinical leadership will help to develop and facilitate this. All doctors are clinical leaders; from day one on the ward they take responsibility for patient care and make decisions that affect others, so that leadership is a fundamental part of doctor’s professionalism.”

 

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Readers' comments (25)

  • It's the Consultants name that goes above the patients bed. It is never the Ward Managers though is it, it's usually that days 'named nurse' even though that nurse may be on days off, on annual leave or on nights and may not have even met the patient.
    The 'buck stops here' is not a very helpful phrase, no one member of staff is ever going to be fully responsible for a patients care, that is why we have medical 'teams', we don't have nursing teams though do we, we just blame the nurse who happens to be on duty when something happens.
    Everyone, at all levels and from all disciplines, has some responsibility toward a patients care.

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  • Isn't the CEO ultimately responsible for all the patients care?
    Who is ultimately responsible for ensuring all their staff are trained to do their job properly?
    Where exactly does the 'buck stop'? at the top?

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  • When I was I hospital I only saw my consultant twice, he didn't do my op either. What's the point in expecting him to be responsible for my care.
    I hardly ever saw the same nurse twice, how can a nurse be responsible for my care if they are not there?

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  • michael stone

    As I've commented elsewhere today, will JH be as keen to 'shine light on' decisions and behaviour he and his political colleagues are involved in ?

    I'm all for proper care, and honesty about mistakes: I'm also against witch-hunting those people who make 'honest and apparently unavoidable' mistakes (but the lessons need to be learnt and systems, etc, inproved when those things happen, where that is possible), while wanting deliberate bad behaviour punished, and professional lack of competence addressing.

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  • The GMC, NMC and CQC all have a part to play is 'where does the buck stop', as do hospital management.

    In the good old days each patient had a named nurse who was there when the patient was admitted, devised their individualised care-plan, handed over that care to the associate named nurses when they went off duty, planned their discharge home.

    Nowadays the 'named nurse' will be someone to blame, probably in their absence, when a patients care is not up to the standard expected.

    I have come on duty after days off to find I have been a named nurse to patients who have either gone home or are going home that day.

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  • Someone's head should definitely roll. Someone meaningful to show where the buck stops. I know..... How about the Health Secretary? Oh wait a minute......

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  • I read this as another way for Mr Hunt to say "Look, the NHS is ineffective, let me bring in a private medical system that can screw the whole country over".

    The buck stops with the Minister for Health but for some reason he always has someone else to blame.

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  • Two things ocurr to me:
    1) isn't Mr Hunt the ultimate responsible officer for health care in the UK, so why is he looking to shift the blame...if things are as bad as he describes he should resign...but being a despicable maggot of course he won't.
    2) Isn't the surgeons who afraid to own up to their own work, by refusing to have personal stats published I think that they should remember about people in glass houses.


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  • My father died recently 2 days after being admitted to hospital I don't want to say too much as there is the possibility we will take legal action.

    What I will say is that at every level from Gp to Consultant down to Healthcare assistant my father was failed.

    We requested the notes and it portrays a disaster unfolding. The Drs missed vital information that was staring them in the face. The nursing documentation was pathetic, fluid charts not completed haphazard observation despite a requirement for 2 hrly obs. An Early warning score system not fit for purpose.

    Of course the care plans were completed A waste of time and effort if ever there was one , half state the obvious ( just how much detail do we need to write down in order to shower somebody?) yet the important points ignored.

    It has confirmed to me that nurses aren't taught to think for themselves , that there is far too much paperwork in the system and that needs to be rapidly addressed . Most importantly, there needs to be one EWS system standardised for the whole of the NHS.

    I am going to battle for change. I am not going to let my dear Dad's unnecessary demise be in vain. I write as a nurse hanging her head in shame at the moment at how pathetic our profession has become.

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  • if only all doctors and nurses were trained to the same high standard, if only all staff were trained and suitably competent to deliver a high standard of care to all patients.
    the nhs has changed so much, staff and patients are shunted around, staff don't specialise, staff are not always adequately trained - even the role of the ward sister/charge nurse has changed, how many of them are moved to 'problem' areas to sort out staff issues, safety issues etc. when they don't have any experience of that group of patients.
    how can 'senior' staff be expected to teach junior staff if they don't have experience themselves or are not really that good.

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  • Mr Hunt - the buck stops with you me old matey. that's what we pay you for.

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  • When is someone going to be held accountable for this disaster?
    We had Midstaffs and no one was prosecuted & now we have a CQC cover up over baby deaths in Cumbria.
    - The state regulator being corrupt is the final straw

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  • tinkerbell

    Anonymous | 21-Jun-2013 2:14 pm

    Agree. Think we're all be softened up for the final blow.

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  • Forget putting up an innocent nurses name above the patients bed. The hospital management, the so-called regulatory bodies and the government are responsible for the state of the NHS, they should be held accountable, until they are nothing will change, they will sit in their ivory towers and let everyone else take the blame.

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  • Just a suggestion, why not run the NHS down to the ground, slowly sell the 'failing hospitals' off to the highest bidders and gradually privatise health care in the UK. Do it drip by drip and no-one will notice.
    That way only the very sick and most in urgent need will get 'care free at the point of access' or whatever the phrase is and the rest of us have to pay more one way or another.
    I could pay even more tax than I already do and as a health worker I could take a cut in pay, work longer hours, work until I am half dead wheeling myself around the ward with a zimmer frame dishing out a few pills.
    Oh yes, I forgot, you'd already thought of that.

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  • well mr hunt now your up to your neck in it and as full of it the next step is to resign because the is a lot of angery people about preferably by the 10' o clock news or at least by monday thankyou.

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  • maybe, just maybe there is a plan to sell off the NHS.
    if staff are set up to fail then each trust will have to close down, then they can be taken over by a private company and it won't be the governments 'problem' any more.
    just keep on with the unsafe staffing levels, poor skill mix, increased demand, poor resources, useless managers and it will all work out just as planned.

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  • tinkerbell

    Anonymous | 21-Jun-2013 1:03 pm

    I agree, my instincts, as Mr Hunt puts it, tell me that all but essential paperwork should end, then nurses will be able to get back to nursing.

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  • tinkerbell

    desertdeserter | 21-Jun-2013 12:39 pm

    Everything that Hunt says sounds good, but sadly think you have your finger on the pulse of his true motivation.

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  • Funny the RCN were not there at the launch. Shows how much the minister values the views of nurses.

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