Image © Zolnierek
Back in 2000 the Chief Medical Officer, Sir Liam Donaldson, chaired a piece of work commissioned by the then Secretary of State for Health, Alan Milburn, entitled “An Organisation with a Memory - Report of an expert group on learning from adverse events in the NHS”. We are now 18 years on and still some of the recommendations from then have not been implemented.
Key comments from that work:
“Once potential and actual risks have been identified, they must be properly analysed to identify lessons for policy and practice. Lessons can be extracted from the pool of available information through analysis, but then need to be distilled – to make sure that the essence of the learning points is properly captured – and their validity tested in theory or practice.”
“The second part of the learning process, once sound solutions have been derived, is to make sure that they are put into practice. Learning points need to be translated into practical policies and actions that can be implemented at the appropriate level. These practical changes then need to be prioritised, to provide a clear agenda for action, and disseminated to the relevant audience. Training is a vital tool in ensuring that information on change is both disseminated and acted on.”
We are all encouraged to learn from our mistakes and also to learn from the mistakes of others. On top of this we have a duty of candour to patients to explain to them when we have made a clinical error. We hope that they would understand that we are human and we err, and yet still some cases go forward to formal complaints and then some to litigation. As medico-legal experts we see the chain of events in full technicolour from the index incident, through the immediate explanation to the patient, the internal investigation and then the final end point of a letter of claim.
We review a case in the cold light of day from the comfort of our study and whether we act for Defendant or the Claimant we see the sequence of errors which occurred and, in line with our overriding duty to the Court, we have to determine what errors happened and how. I often think to myself “there but for the Grace of God go I”.
My experience is that patients want an apology and to know that it will never happen again, and we are good at instituting change locally to make sure the learning points are acted upon, but we are not good at disseminating that information across the whole NHS.
NHS Improvements does excellent work in detecting and implementing learning strategies that address system errors and serious incidents that result in death or serious harm, but fails to address lower level clinical errors, which are still happening throughout the NHS and causing repeated avoidable harm to patients. Front line clinicians are key stakeholders in patient safety and they need to be involved in the detection and reporting of clinical errors, but also in the assessment of these errors, identification of common themes and learning points and the subsequent dissemination to the clinicians who need to hear these safety messages.
In my medicolegal work I see a lot of cases where a clinical error is repeated time and again and this is not being picked up. The simple clinical learning point is missed and the opportunity to intervene to prevent harm to another patient lost. I consider to this to be a major system flaw within the NHS. Many hundreds of NHS manhours are spent investigating and undertaking root cause analysis; however, the learning points, which are often simple, are actioned locally but not disseminated throughout the NHS.
Don’t get me wrong, from a selfish perspective I love seeing the same error happening, as I can cut and paste from previous reports, the background research is already done and I can still charge my usual fee to make up for the cases where I unexpectedly get four lever arch files of notes to review on what I thought would be a simple case. However, it breaks my heart seeing the same avoidable error happening time and time again. How can we learn from these errors? A case report in a journal? Who really reads them? Present the case at a conference? Who’s awake and listening?
Around 2,000,000 incident reports are received by the National Reporting and Learning System (NRLS) each year, on over 130,000 disease and injury types, 6,000 medication types, 9,000 treatment modalities and an almost uncountable range of medical devices used within the NHS, according to data from direct communication with NHS Improvements (NHSI).
Of the 2M incident reports per year submitted to NHSI, 30,000 are serious incidents or patient safety incidents which cause death or serious harm. There are also 200 ‘dives’ which look at approximately 20,000 lower harm incidents. Taking out these 50,000 scrutinised incidents, there are 1,950,000 incidents reported per year that receive no scrutiny whatsoever and are not read by anyone outside the local Trust. This means that 97.5% of all clinical incident reports via the NHSI are not scrutinised externally at all, and all those potential learning points are missed and not appropriately disseminated. Assuming that only 1% of those unscrutinised incidents refer to avoidable clinical errors, this means that there are 19,500 episodes of clinical harm due to avoidable errors per year that are going unrecognised. Not addressing that gap is letting patients down, increasing the risk of harm, hampering doctors’ abilities to learn from others’ mistakes and increasing our litigation bill.
Clearly the key is identification of these learning opportunities, and currently NHSI does not have the facilities or systems to assess every clinical error. We need a mechanism for identifying which incident reports have a clinical learning message, and targeting those for particular attention. Rather than scrutinise them after the fact, the logical route is to ask those clinicians/allied professionals submitting the report to identify if there is a clinical learning point, thereby flagging up their importance so they can be singled out for special scrutiny and any learning points picked up. The new data processing systems being developed by the NHSI gives us an ideal opportunity to facilitate data entry processes which can make it easy for those entering data on incidents to highlight any potential learning points.
Albeit potentially delayed for several years, due to the length of time litigation takes, we have a system already in place whereby the worst clinical errors which cause harm to patients and may be negligent are already picked up and assessed by highly skilled clinicians in the field, ie, you, my learned audience. Part of our work as an expert is to determine where things went wrong and work out whether there was a breach of duty. So, we, as experts in the field, have already done the hard work and identified the error and the learning point. We work on the front line and can determine what is truly an avoidable clinical error and determine what learning point should be disseminated to our colleagues.
I would have no hope of determining whether a clinical error in nephrology was important and not just some weird unfortunate and unpredictable happenstance. Currently NHS Improvement have a group of health professionals such as nurses, doctors, pharmacists, physios, midwives, and paramedics who look at the information submitted but do they have the expertise to pick up the nuances of what are actually important clinical learning points for clinicians at the coal face? You, my fellow expert do.
A clinical error was made, a patient came to harm, there is a clinical learning point which, if appropriately disseminated to the front-line clinician, could prevent harm to another patient. A medical expert witness will determine this as part of their work and, I hope, be keen to help disseminate this message to their colleagues and trainees within their speciality.
How should this valuable and patient centred information be disseminated? The Colleges play a vital role but there is inconsistency in the delivery of these important messages. Not everyone is a College member and arguably those who are not may be the ones who we need to target the most with patient safety messages. For the Royal College of Ophthalmologists approximately 90% of Ophthalmology Consultants, 50% of Trust and SAS doctors and all trainees in recognised training posts are members. It is not known how many trainees in non-recognised posts are members. These clinicians do not receive communications from their College. Do we accept that, even if the College systems are robust in disseminating this information, these clinicians are left out?
Avoidable harm is repeatedly happening which can and should be avoided. Should we neglect this issue because it is not a core part of our role as an expert witness or should we work together to develop a robust and consistent process to detect repeated clinical errors from the litigation we see, develop learning points for those errors, and then make sure they are securely, reliably and consistently disseminated to the people who need to hear them, the front line clinicians.
Work has already commenced with NHS Resolutions exploring piloting a mechanism to study the Ophthalmology litigation and distil out recurrent errors in the hope of feeding back learning points to the wider NHS.
The proposal which I hope to be working with NHS Resolutions on is that all expert witnesses are asked a simple question; “was there a clinical error that caused harm?”. If the answer is yes, then the expert will be asked to describe the learning point in less than 250 words. This anonymised reportwill be sent to an expert in that clinical field who will determine whether there is a learning point or whether an error is being repeated. The aim of this work is not to develop definitive guidance or proscriptive learning points but rather to disseminate points for practice reflection.
The same clinical errors are happening again and again. They do not reach the serious harm criteria for patient safety alerts and some are not system errors (which the current NHSI/NRLS processes handle well). They do not warrant NICE guidance or National Patient Safety Alerts and so they get left behind and patients are coming to harm time and again from avoidable clinical errors. Some of the worst cases of harm result in litigation and only a few go to Court where a formal judgment is reached. All however go through the hands of the medical expert and the knowledge of those clinicalerrors and any learning points therein are being missed. As a medico-legal profession we have the opportunity to make a difference and protect patients from harm through cooperation and a teamwork approach with NHS Resolutions and the wider NHS.
Published by: