Memorandum by Mr Arthur Briggs (PS 22)
PATIENT SAFETYA LOW PRIORITY OF ACUTE
TRUSTS, PCTs & HEALTH AUTHORITIES
My submission is a personal one, though I am
a member of AvMA. My background before retiring was as a Project
Engineer working in the Oil Exploration and Production Industry.
Though living in Scotland, my experience is related to the Hertfordshire
My submission is centred on:
the failure of the WHHT to put into
effect a Risk Management system, despite the number of related
policies issued by the DoH, CMO & NAO;
the complacency and ineffectiveness
of the various regional bodies in ensuring patient safety in the
the need to change the culture of
the NHS Management from the Trust level up to and including the
1.1 Patients admitted to some Acute Hospitals
are exposed to an unacceptably high risk of HAIs and untoward
incidents. Some die unnecessarilyThese incidents could
be reduced considerablysee statistics sections 2.1 &
1.2 The policy "Risk Management in
the NHS" was introduced in 1994 as a guide to reducing these
incidents. Sir Duncan Nichol, Chief Executive of the NHS, stated
in the foreword that Risk Management was no longer an optional
extra. Unfortunately, it was only a recommendation.
Despite this and subsequent policy documents,
Risk Management is not universally implemented by NHS Trusts.
In sections 2.3 to 2.5 I have discussed the advantages of having
a Risk Management Policy based on the CNST Clinical Risk Management
1.3 In 1999 the West Herts Hospital Trust
(WHHT) was at level Zero of the CNST Risk Management Standards.
My complaint about the lack of a Risk Management system, QA and
auditing was ignored. It has still only reached level 1. Not a
reassuring record in terms of patient safety and confirms that
enforcement is required rather than guidance.
1.4 My submission sets out the history of
Patient Safety events in the WHHT against the Patient Safety related
national policies issued over the same period. Compare the reality
of Patients Safety in the WHHT section 3.2 against the objectives
of Policies section 3.9
1.5 During this period the PCTs and Health
Authorities in their various forms failed to take remedial action.
These bodies ignored complaints about the problems in the WHHT
and their complacency. Protecting incompetent managers was considered
more important than protecting Patients. Their ineffectiveness
is covered in sections 3.4 to 3.8.
1.6 I have concluded with proposals for
improving Patient Safety in section 4.ie
A Clinical Risk Management System
to be put in place within an agreed timetable, say 2/3 years.
A Complaints System that is Operated
Independently of the NHS Trusts where harm or death has occurred.
The identification of Incompetent
Trust Managers who should be retrained or made redundant
The introduction of a set of core
standards which are guaranteed.
PCTS & StHAs to be accountable
for ensuring Patient Safety policies are met in Acute Trusts.
2.0 RISKS TO
2.1 Statistics for Patients Admitted to Acute
Hospitals in England.
2.1.1 a) 1 in 10 patients suffer an untoward
b) 1 in 11 patients acquire a Hospital infection
2.1.2 1 in 3 of 1800 deaths investigated
in 2005 by the National Patient Safety Agency were unnecessaryie
at least 600 patients died unnecessarily.
There is estimated to be at least 34,000 deaths
/ annum in the NHS caused by errors.Some authorities believe
this is an underestimate but the exact number is not known (A
Safer Place for Patients Key Facts)
2.2 Are these Incidents & HAIs Avoidable?
2.2.1 These untoward incidents and high
infection rates are due to a combination of human and system failures.
While all failures cannot be avoided, there is a lot that can
be done to reduce the numbers of failures, including learning
Referring to A Safer Place for Patients -Learning
to improve Patient Safety NAO 2005 30% to 50 % could have
There is no reason why these reductions cannot
be achieved if given a higher priority.
2.2.2 Essential to reducing incidents and
infection rates are the changes set out in paragraph 1.6 and section
2.3 Risk ManagementDefinition
Risk Management covers all the processes involved
in identifying, assessing and judging risks, assigning ownership,
taking actions to mitigate or anticipate them, and monitoring
and reviewing progress. (Definition from Standards for Better
The more effective the risk management system,
the higher the standard of patient Safety.
2.4 CNST Clinical Risk Management StandardsIntroduced
2.4.1 A summary of the CNST Clinical Risk
Management General Standards 2005 issue is attached
(appendix 1). Even a layman can understand
the benefit of being treated in a hospital which is compliant
with levels 2 & 3 rather than level 1. eg using Standard 1:
Learning from experience
2.4.2 An Acute Trust in which incidents
and near misses are reported in 100% of all specialities and can
provide examples of how that information has been used to improve
patient safety will be inherently safer than a Trust at Level
1 which only reports incidents and near misses in 50% of all specialities.
2.4.3 Reporting some incidents ( a level
1 requirement) is not much good if the Management takes no action
and does not learn from experience.
2.4.4 A Trust progressing from level 1 to
level 3 will increase the level of Patient Safety. The NHSLA authority
actuaries would be able to provide detailed evidence of the benefit
of such a system in terms of improving Patient Safety and reducing
2.4.5 A measure of the improvement in Patient
Safety is that for compliance with each level, there is a 10%
reduction in the contribution to the CNST scheme up to a maximum
of 30%. For the WHHT, paying a gross contribution of £4.2
million in 2004, there would be a financial saving and considerable
improvement in Patient Safety if operating at level 3.
2.5 Consequences of No Risk Management System
2.5.1 Conversely, without an effective Risk
Management system, an integral part of governance, patients will
be at greater risk. Managers will not be in a position to manage
and optimise their use of limited resources.
2.5.2 A Clinical Risk Management System
is not considered by the NHSLA to be to be in operation until
level 2. Unfortunately for patients 45% of Acute Trusts are still
at level 1
2.5.3 As the CMO has stated, Patient Safety
needs to be a core non-discretionary activity. CNST standards
are measurable and so are the benefits in terms of Patient Safety.
3.0 NHS BODIES
3.1 Acute Trust BoardsAccountability
for Patient Safety
Accountability rests with the chair and board
of each NHS organisation. Following the NAO report on "Health
and Safety in NHS Acute Hospitals", HSG (97) 6Annex
AManaging Risk, stated that the Chief Executive of the
organisation has the overall statutory and operational responsibility
for managing Health & Safety. Ideally an executive Director
should be allocated clear responsibility for Health & Safety
Risk Management across the whole organisation.
3.2 WHHT since 1999History of Major
3.2.1 Some Trusts, such as the WHHT, will
be more risky than the general statistics indicate. I would not
want to undergo treatment in such a hospital except as a last
3.2.2 The low standards of Patient Safety
of the WHHT have been confirmed over the years by a series of
a) In 1999, the number of women patients
(300 to 400) damaged by Drs. Kane & Rosenberg became Public.
This was followed by an "Independent Inquiry" into these
incidents and the "Effectiveness" of the WHHT Complaints
system. The report was issued in 2002.
b) The HSE in April 2001 issued a warning
letter to the WHHT, (and the Herts Partnership Trust and the St.Albans
PCT) concerning their failure to train clinical staff in Infection
Control (including MRSA).
However, in August 2001 Mr.S.Eames, Chief Executive
of the WHHT, advised me that collecting data on HAIs was unreasonable
& too expensive.
c) The Public Health Laboratory Service MRSA
League table for 20012002, placed WHHT 6th from top.
e) The HSE in 2003 issued 3 Improvement Notices
because of the Trust's failure to maintain water systems and prevent
Legionella, a potentially lethal failure.
f) CHI awarded the Trusts zero stars for
2003/2004. Simultaneously, the Trust was operating at Level 0
g) The DoH who in November 2003 "imposed"
a three year comprehensive Modernisation/ Improvement Plan
Mr. John Bacon, Group Director, Health and Social
Care Delivery, would be able to provide details
h) The Healthcare Commission in 2003/2004
reported that for the second year running, the WHHT did not provide
or did not have data for:
Emergency re-admissions following
Deaths following selected non-elective
Emergency re-admissions following
discharge for a fractured hip.
Infection control rated at level
2, as was hospital cleanliness
This was despite or because of the study into the
high rate of MRSA infections and deaths in the Hemel Hospital
issued in March 2001.
i) The Audit Commission commented on dodgy
data and other matters.B&H StHA Annual Audit Letter
j) A&E problems which were evident for
several years, requiring 3 reports and another major incident
before there was a significant improvement. On several occasions
the Trust had ambulances queuing at doors.
k) The Trust operated between 2003 &
2006 without a capacity plan.
l) In January 2006 the HSE prosecuted the
WHHT for failing to maintain hospital water systems and dispose
of clinical waste safely. (amongst numerous other matters)
m) The HC in October 2007 awarded the WHHT
a double weak rating.
n) The Trust in 2007 was awarded a position
17th from the top of the Clost. Difficile League,
o) In Jan 2008, the Healthcare Commission
graded the Trust's Maternity Services the worst in England
p) PEAT teams in the past classified Trust
Hospitals as Double Red, rarely green. The WHHT Trust managers
blamed the problems of dirty hospitals on the cleaning contractors.
The Hertfordshire Health Authority Performance Director, Mr.A.Morgan,
would not or could not explain why the Trust managers continued
to pay the contractors for substandard work.
q) The low standards of Care of the Elderly
wards continued over several years, confirmed by NHS staff, the
CHC and the Public & Patient Forum.
3.2.3 DoH Inspection 2007
The basic hygiene & problems identified
in 1999 and subsequent years should be history. In August 2007
the DoH inspectors confirmed they were not. The following actions
were implemented after the visit:
two isolation wards were opened;
a rolling programme of deep cleaning
with hydrogen peroxide nebulisers has been implemented, in line
with the Secretary of State's proposals;
restrictions have been placed on
the use of cephalosporins, quinolones and protein pump inhibitors;
the antibiotic policy has been revised
and new flash cards for use by doctors issued;
the hand hygiene policy has been
levels of general cleaning have been
the 24 hour rapid response cleaning
team has been re-established;
there is a zero tolerance policy
on hand hygiene with dismissal for those who repeatedly fail to
comply with hand hygiene policy;
the bowel management system has been
continued from an earlier trial;
root cause analysis for Clostridium
difficile positive cases has been implemented; and
roles and responsibilities of individuals
from board to ward have been clarified.
22.214.171.124 This brief history confirms that
simply issuing Patient Safety policy documents to such Trust Managers
is not effective in improving Patient Safety.
126.96.36.199 Using the CNST General Standards
as a measure of Patient Safety, the WHHT is still at Level 1,
another indicator that Patient Safety is not a priority.
188.8.131.52 This series of events is not comprehensive
and more detailed information was available to the various bodies
with responsibility for ensuring WHHT delivered services that
were Safe for Patients. Quite clearly, the bodies listed below
3.3 PCTs Role in Patient Safety in Acute Trusts
3.3.1 South Hertfordshire PCTs Prior to
The PCTs in the 2000 Service Level Agreements with
the WHHT specified standards for the commissioned services including
a requirement to have joint audits. It took almost 3 years to
persuade the Dacorum PCT to carry out a half hearted audit of
the WHHT Care of the Elderly Wards, although there were ongoing
Evidence that Patient Safety was not a priority.
3.3.2 West Herts PCTAfter the merger
of the Hertfordshire PCTs
The West Herts PCT was awarded a double weak
grading by the Healthcare Commission for 2006/2007. Not surprising
as managers from the Beds and Herts St.HA and the old PCTs were
simply shuffled across to the Board of the new PCT.
When such levels of incompetence are accepted
as the norm, their inefficient management of both Clinical and
Financial Risks obviously reduces the funding available for patient
care. One example is the allocation of approximately £20
million to the Beds &Herts St.HA authority for the increase
in Intermediate Care Beds. ( see HSC 2000 / 001)
3.4 Indirect InvolvementImpact of Reduction
of Intermediate Care Beds
3.4.1 The NSF for Older People included
a programme, with dates, for meeting the standards including the
provision of additional Intermediate Care Beds to reduce the problem
of bed blocking in Acute Trusts.
The West Herts PCTs:
were given money to increase the
number of Intermediate Care Beds, (see HSC 2001/001 Intermediate
Planned in 2003 to increase Intermediate
Care Beds by 90.
By 2006, reduced the number of Intermediate
Care Beds by 35%without carrying out Risk Assessments of
the impact of bed closures
Complained in the Acute Services
Review that shortage of Intermediate Care Beds was resulting
in payments to the WHHT and E&NHT Acute Trusts of £22
After taking 12 months to "unpick"
PCT could not explain where money allocated by HSC 2001/ 001 had
As part of the same "efficiency"
exercise, increased Acute hospital bed occupancy to 95% +
3.4.2 In the WHHT, this contributed to an
increase in premature discharges, readmission rates & hospital
infections. As Ms. A. Walker, Chairwoman of the Herts PCT, eventually
admitted, the impact on Patients Safety was not considered.
3.5 Strategic Health Authorities Role
3.5.1 According to Shifting the Balance
of Power issued in 2001, SHAs were supposed to performance
manage Acute Trusts.
Mr.I.White, Chairman of the Beds & Herts
StHA despite the history of problems in the WHHT, refused to find
out what the Clinical Risk Management Department had been doing
for the previous 10 years.I asked the question in August
Unfortunately, he refused to investigate, advising
it was more important to look to the future. Confirmation that
he considered protecting incompetent staff more important than
protecting patients' health.
3.5.2 A response to another Patient Safety
question, raised at a Board meeting, was that Patients had a choice
at which hospital to have treatment & could therefore decide
which was safest.
3.6 CHI / Healthcare Commission
The Healthcare Commission can carry out reviews
and investigations but only makes recommendations which the Trusts
can ignore eg the Stoke Mandeville C.Diff. disaster where 33 patients
were killed and 334 infected in two separate outbreaks.
The HC report stated that "The Trust
failed to demonstrate that it took the necessary steps to identify
risks and implement changes to protect the interest of patients"
A bigger C.Diff. disaster occurred in the Maidstone
& Tunbridge Wells TrustDemonstrating that the HC is
unable to take effective actions to prevent these disasters
3.7 Effectiveness of PCTs, St.HA and Healthcare
Commission in Ensuring Patient SafetyConclusions:
3.7.1 As the DoH Inspection confirms, Patient
Safety is not a priority of either the PCTs or the St.HA.
3.7.2 The Healthcare Commission can only
make recommendations and take limited action (the issue of improvement
notices related to hygiene) but cannot take enforcement action.
3.7.3 The NHSLA assessment also confirms
that in terms of Clinical Standards, a Risk Management system
is still not in place in the WHHT. Further evidence that these
bodies are ineffective in improving Patient Safety even where
Trusts have long term problems.
3.7.4 These bodies did not consider it their
responsibility to ensure policies contained in the Documents listed
below were applied.
3.8 National Policy DocumentsEffectiveness
in Improving Risk Management & Patient Safety
3.8.1 Some of the policy documents issued
before and during the period of the WHHT events are listed below:
1994 Risk Management in the NHS
1999 Governance in the new NHSHSC 1999/123
2000 An Organisation with a MemoryDoH
2003, Achieving Improvement through Clinical
Governance- A NAO progress report noted "that progress
in implementing clinical Governance is patchy, varying between
Trusts, within Trusts and between components of Clinical Governance.
There is, not surprisingly, scope for improvement
inter alia improving processes for managing risk and poor
Overall, key features of the organisations that
have been better at improving Quality of care are quality of leadership,
commitment of staff and willingness to do things differently."
3.8.2 There followed another series of Policy
2005A Safer Place for Patients : Learning
to improve Patient SafetyNAO Report
b) 2006A Safer Place for Patients. Learning
to Improve Patient Safety: HC Public
2006Safety FirstCMO's Report:
3.8.3 A series on Hospital Infections was
also issued by the NAO including
2000The Management and Control of Hospital
Acquired Infections in Acute NHS Hospitals in England
2004Improving Patient Safety by Reducing
the Risk of Hospital Acquired Infection: A progress Report
3.8.4 Safety FirstExtract
184.108.40.206 In foreword to "Safety First:
A report for patients, clinicians and healthcare managers"
the CMO outlines four major themes, first being,
"We need to redouble our efforts to implement
systems and interventions that actively and continuously reduce
risk to patients." Recommendation 1 of his report dealt with
220.127.116.11 Recommendation 1
As the next round of national goals, priorities
and targets are being established from the period from 2008, it
is important that the NHS takes steps to ensure that patient safety
is further deeply embedded as a core principle that underpins
Patient safety needs to be a core, non-discretionary
part of the agenda for 21st-century healthcare in this country.
The setting of national priorities should explicitly take this
into consideration and be informed by overall analysis of NRLS
(National Reporting and Learning System) data linked to existing
safety-related targets and drawing on other relevant national
information sources through the National Patient Safety Observatory.
18.104.22.168 Unfortunately the report does not
include a set of mandatory clinical standards. Nor does it set
out a timetable for change, only a date for starting talks about
change. What will this achieve?
22.214.171.124 These policies demonstrated that
those who were producing them had identified the problems and
126.96.36.199 Relating the issue of these policies
to the events in the WHHT demonstrates that the policies were
not being put into effect and Patient Safety was still a low priority.
188.8.131.52 The disparity between the Policies
and the situation in the WHHT highlights the need for a change
in the NHS Management culture up to and including the DoH. "We"
need to take action instead of simply issuing further policies.
The WHHT is not the only Trust with Patient Safety problems.
4.0 What the NHS should do next regarding
The steps referred to by the CMO in Safety
First need to be set out in a timetable & monitored as
closely as waiting list targets have been. These should include
4.1 An Effective Clinical Risk Management
System must be NonDiscretionary
4.1.1 The 2005 CNST Risk Management System
was developed over a period of 10 years and is administered by
a relatively independent organisation. A short programme of 2
or 3 years to get all Trusts to level 3 would improve Patient
safety. While not comprehensive it could be further developed.
4.1.2 Trust managers that have not complied
with Levels 2 & 3 CNST at the end of programme should be considered
incompetent and retrained or made redundant. Managers have to
realise they are no longer managing cottage hospitals of the 1940s.
4.2 An Independent Complaints System
4.2.1 I made a complaint in 1999 about incompetent
management and an absence of QA and auditing to Mr.Eames (at time
Chief Executive). The very people I was complaining about were
those who were dealing with my complaint and took no action about
This complaint was based on several other problems
my mother experienced including filthy wards and poor staff hygiene.
Matters criticised by the DoH Inspectors in August 2007
4.2.2 Obstruction and corruption of the
complaints system is quite prevalent and a third change is underway.
This is another example of changing the system instead of removing
the cause of the problem. ie the incompetent Managers who obstruct
and corrupt the complaints system.
4.2.3 Until the basic problems of having
incompetent NHS managers investigate their own incompetence is
resolved, learning from mistakes when caused by system failure
or other matters for which the Chief Executive is responsible,
will not happen.
4.2.4 A complaint system independent of
the NHS is required for instances where death or harm has been
caused to a patient. The body dealing with these complaints must
also be given the power to enforce changes should recommendations
be ignored, as with the HSE.
4.2.4 Patients and Public should be involved
in the auditing of the complaints system, whatever form the new
4.3 Selection & Regulation of NHS Chief
Executives and Managers
4.3.1 Unfortunately there is no body for
regulating NHS Managers. Therefore incompetent managers can and
do float about the system adding nothing to Patient Safety.
4.3.2 The main cause of the major disasters
that have come to light in the last three years has been the incompetent
managers of the Stoke Mandeville and Maidstone & Tunbridge
4.3.3 In general, the problems of the WHHT
have also been caused by management failures over the years. The
damage caused by Kane & Rosenberg was extended by several
years because the Trust's management ignored complaints and failed
to take remedial action resulting in harm to hundreds of patients.
4.3.4 To resolve this problem, it is necessary
to check the performance of the Trusts Managers, which existing
regulatory bodies cannot do, and either retrain or make them redundant.
4.3.5 The WHHT is now on the 5th Chief Executive
since I became involved which indicates there is also a problem
with the selection of Chief Executives. Good management skills
should be considered more important than PR skills and years of
service in the NHS when selecting managers.
4.4 Introduction of Guaranteed Standards
4.4.1 Ms Hewitt in September 2006 stated
that a regulatory system to guarantee standards was one of the
4 key elements of NHS reform.
These standards need to be set out, incorporated
into a timetable and enforced. Patient and Public Forums must
be involved in the auditing of these standards.
4.4.2 The CHRE is in place with a review
of Health Professionals Regulators already complete. However,
the Self Assessment Process needs an auditing procedure to ensure
that assessments are accurate.
The auditors should include members of the public