Examination of Witnesses (Questions 120-139)
DEPARTMENT OF
HEALTH AND
NATIONAL PATIENT
SAFETY AGENCY
16 JANUARY 2006
Q120 Chairman: Why?
Professor Sir Liam Donaldson:
Because they will not be able to ignore it. They are going to
be tested in examinations which determine their career progress.
Q121 Chairman: As I understand these
questions that Mr Clark was putting to you, there is too little
feedback. People just do not feel that the work of this agency
is making a great deal of difference. That is as I understand
his 10 minutes of questioning.
Professor Sir Liam Donaldson:
Ms Williams has mentioned the feedback that they have done. I
have regularly, in my Chief Medical Officer's newsletter to all
doctors, mentioned patient safety, I have mentioned the role of
the agency, I have emphasised the importance of reporting. As
I say, it is a world first to have in the training curriculum
a competency for all doctors on patient safety. We have a lot
more still to do but we are taking some quite strong steps.
Q122 Mr Williams: Sir Nigel, you
found succour in table 23, page 67, on the international comparisons?
Sir Nigel Crisp: I do not know
if I found succour in it.
Q123 Mr Williams: You were quoting
it as showing not unreasonable results as far as the country was
concerned.
Sir Nigel Crisp: These were results
over a number of years and I think what I said was that I was
not quite sure what this showed, and then we went on to Sir Liam
talking about international comparisons that he was aware of.
I was not particularly taking succour from that. It seems to me
that that shows really quite a mixed picture.
Q124 Mr Williams: It is meaningless,
is it not, as a table? It has only got two London hospitals representing
the whole of the UK and there, when it comes to preventable adverse
events, we are second worst out of the whole list in the table.
Sir Nigel Crisp: I am not sure
that table offers us much insight.
Q125 Mr Williams: That is all right,
as long as you are not shouting behind. I probably misunderstood.
Sir Nigel Crisp: That is what
I was intending to say.
Q126 Mr Williams: I just wanted to
make sure no-one laid any confidence on that because it is statistical
gobbledygook. It is utterly meaningless. The reality is better
reflected, is it not, on page 25, and very worryingly reflected,
where you deal with the number of incidents?
Sir Nigel Crisp: Yes.
Q127 Mr Williams: And in table 6.
I know you must be as worried about this as I would be, but it
seems to me when you get a range from almost nil at one end to
13,000 at the other end between trusts, that someone is not telling
the truth, are they?
Sir Nigel Crisp: I think the table
on page 6 actually reflects reporting practice rather than number
of incidents, and that is partly because of the timetable.
Q128 Mr Williams: Exactly, that is
what I mean, someone is not telling the truth because they are
not reporting, they are not recording.
Sir Nigel Crisp: I have to say
some of these trusts only came on to the reporting system during
the course of the year in question I think.
Q129 Mr Williams: If you look at
the table, the median figure, because you cannot get an average,
comes out at 3,700. The worst is three times worse than that at
13,000 in that year.
Sir Nigel Crisp: Yes.
Q130 Mr Williams: Then, at the other
extreme, you find people having recorded nothing at all. Either
they are unbelievably competent or they are just concealing the
truth, or not interested in finding the truth.[7]
Sir Nigel Crisp: Or possibly they
are not connected to the system or they became connected to the
system during part of the year.
Q131 Mr Williams: It is the median,
so you cannot really say that.
Sir Nigel Crisp: I beg your pardon.
Yes.
Q132 Mr Williams: You referred to
a figure of 50,000 per month and I missed what you were talking
about there.
Sir Nigel Crisp: What we are getting
at the moment is 60,000 incidents being reported to the NPSA a
month.[8]
In this document it was about 40,000, which was the figure quoted
in this Report, which shows how fast it is increasing.
Q133 Mr Williams: So that is 720,000
a year?
Sir Nigel Crisp: Something of
that sort, yes.
Q134 Mr Williams: We are told by
the NAO and it is reflected in this table that only 24% of the
trusts bother to routinely tell patients when they have been involved
in an incident. It could happen under an anaesthetic, it could
mean you were given drugs which you should not have been given.
How on earth can they justify 1:4? Or, put the other way, how
can they justify 3:4 not telling the patient?
Sir Nigel Crisp: I agree, I would
not want to justify it.
Q135 Mr Williams: So what are you
going to do about those? It does have consequences, does it not?
If you have not been informed it could well be that it has had
a medical effect which is serious to you and you do not even know
the hospital was responsible, but also if it is not reported then
the GP does not know about it, so in any subsequent diagnosis,
looking at this patient, he is unaware something happened in the
hospital which could have been the cause or contributed to the
new situation. That is very, very worrying indeed, is it not?
Sir Nigel Crisp: Indeed, I think
it is, and that is precisely why we are paying so much attention
to this, because these incidents have not just happened because
we are starting to report them. It is actually important we are
starting to report them so we do something about them and pick
them up in the ways you are talking about.
Q136 Mr Williams: If we look at the
number of incidents—I assume these are the incidents recorded
in that table on page 25—the top number reported is 13,000.
Sir Nigel Crisp: Yes.
Q137 Mr Williams: Are we to believe
that three-quarters of those, say 9,000, were not actually reported
to the patients? Is that not what follows from the 24% figure?
Ms Williams: We know that because
of a range of reasons—fear of retribution, the general atmosphere
in which reporting takes place—there are some places where
staff are more nervous of speaking up than others and to tell
patients, but we have issued a policy in September—
Q138 Mr Williams: But there are an
awful lot of patients out there who have been denied the information
they should have had, and in some cases needed to have, and this
could have an effect on their future health and also on their
rights, because if it had been a preventable incident then they
do have a right to take action. It is not antisocial to take action
if you have suffered a serious health injury as a result of something
someone else could have prevented. What are you doing about all
these people who are wandering around unaware they have been the
victims of failures by medics? If you have a constituent who complains
against a consultant and you take it up with the trust, you are
likely to find that the consultant might no longer want to see
the individual who dares to complain. It is stacked, is it not,
against the patient?
Sir Nigel Crisp: I think there
are a number of points here. We are now starting to get this information
so we know what is going on. You can see in various places in
this report, including the stuff for example on the North East
Strategic Health Authority, how they are trying to change the
whole system in the North East to make sure actually it is the
norm that people report, that you do have a no blame culture and
you do get into the position which you are precisely describing
of where we want to be. We have also got, as Sir Liam has said,
the new NHS Redress Scheme which will make it easier for people
to deal with the more minor incidents without getting tied up
into legal issues.
Q139 Mr Williams: If they are ever
told about them.
Sir Nigel Crisp: I agree with
the point you are making. Even though two thirds of these are
things which do not actually harm the patient, they should nevertheless
in principle know what has happened.
Ms Williams: We launched a policy
called Being Open in September, and this year we are running
training programmes for trusts using a variety of techniques for
staff to be aware of the policy where we are saying very clearly
as an agency that you should tell the patient or their relatives,
you should offer an apology and you should involve them in the
investigation and discuss with them what action should be taken
to prevent harm to others. That training programme involves trusts
developing their own policy as to who should tell the patient,
in what circumstances, and actually what we have found is that
staff themselves need training and practice in telling patients.
It is a very traumatic thing for example to tell a family that
maybe an overdose of medication has been given, and what we have
discovered in our work is that clinical staff themselves need
support from their organisation and training in how to do that
and how to do it well.
7 Note by the National Audit Office: Mr Williams
referred to the data the National Audit Office collected (presented
in figure 6 of the C&AG's Report) which were supplied by NHS
trusts directly from their own Incident Recording and Risk Management
systems. The NAO quantification of the number of reported patient
safety incidents in England for 2003-04 and 2004-05 was not dependent
on the trusts being linked to the National Patient Safety Agency's
National Reporting and Learning System. Therefore, an NHS trust
that reported only four recorded patient safety incidents would
have made a similar return to the NPSA if it had been linked to
the National Reporting and Learning System. Back
8
Note by the National Audit Office: As the Permanent Secretary
is referring to the NAO Report it should be noted that the figure
quoted is in fact 85,342 incidents reported to the NPSA between
December 2004 and March 2005, ie over a period of 4 months (at
best 22,000 per month). Back
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