PFPSUS have requested that the U.S. Office of the Inspector General investigate Vanderbilt, the Tennessee Department of Health and CMS to determine if they followed appropriate laws and procedures related to the reporting of this error.

Among the questions posed are:  

• Did the Tennessee Department of Health take appropriate legal action when Vanderbilt did not report the error? 
• Did Vanderbilt commit Medicare fraud when they attributed the cause of death as “natural” on the death certificate? 
• Did CMS appropriately impose any consequences within their powers that addressed Vanderbilt’s manipulation of patient data and failure to report the error?  
• Did Vanderbilt’s actions and omissions violate CMS Conditions of Participation and if so, why weren’t actions taken?  

On the NHS Resolution website you can find more information on making a claim and details of organisations which can help you find a medical negligence solicitor who can guide you through the process and let you know if you have a valid claim.

The signatories of this letter are:

• Peter Walsh, Action against Medical Accidents
• Joanne Hughes, Harmed Patients Alliance
• Rachel Power, Patients Association
• Marcus Green, Action On Pre-Eclampsia
• Dr Kim Thomas, The Birth Trauma Association
• Edel Harris OBE, Royal Mencap Society
• Karen Hillyer, Erb’s Palsy Group
• Jane Plumb MBE, Group B Strep Support
• Paul Farmer CBE, Mind

The first report looks at high-value and fatality-related claims over £1m; the second report assesses missed fractures; and the third report evaluates hospital-acquired pressure ulcers and falls in ED. Each report also contains clear recommendations to help prevent further incidents. One of the main findings across all the reports is that ED clinical services should provide timely identification of diagnoses and treatment plans for patients. This should include what to look out for and actions that should be taken if the patient deteriorates. Good record-keeping and communication to support handover and ‘safety netting’ for patients – where they are followed up in a timely and appropriate manner – underpins the delivery of timely diagnoses and the delivery of effective treatment plans.

The other key clinical issues the reports highlight are:

• access to senior staff review, with appropriate use of multidisciplinary teams working between specialties;
• systems in place for prompt clinical imaging;
• infrastructure for appropriate escalation and handover of clinical details to senior clinical staff and specialist clinicians respectively;
• identification and proportionate clinical strategy regarding patients who regularly attend ED; and
• the benefits of digital solutions to support timely and appropriate clinical decisions for patients.

Analysing the standard of care that might apply to the three different acts in the diagnostic process, the authors identify reasons to think that Montgomery should apply to the communication of a diagnosis. They argue that even in areas where the law is well-established, such as the application of Bolam to the formation of a diagnosis, challenging questions arise that require further attention. Throughout, the framework and analysis that we develop have significant implications for a set of negligence cases, as well as for medical education, clinical guidelines, and patient care.

Key findings:

1. The consequences of NHS negligence are wide ranging.
2. The injury caused by NHS negligence has both direct and indirect costs.
3. Compensation helps people to rebuild their lives.
4. Private treatment is often a key factor in recovery.
5. Compensation can be an effective acknowledgement of what can’t be replaced.
6. Where negligence has caused uncertainty about the future, compensation offers reassurance.
7. The compensation awarded is ‘not life changing’, it simply helps people get back on track.
8. Compensation isn’t about shaming the NHS, but about recognition of wrongdoing.