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In a report published today, AvMA, the charity Action Against Medical Accidents, reveals serious delays in NHS trusts implementing patient safety alerts, which are one of the main ways in which the NHS seeks to prevent known patient safety risks harming or killing patients. The report, authored by Dr David Cousins, former head of safe medication practice at the National Patient Safety Agency, NHS England and NHS Improvement, identifies serious problems with the system of issuing patient safety alerts and monitoring compliance with them. Compliance with alerts issued under the now abolished National Patient Safety Agency and NHS England are no longer monitored – even though patient safety incidents continue to be reported to the NHS National Reporting and Learning System. David said: “The NHS is losing it memory concerning preventable harms to patients. Important known risks to patient safety are being ignored by the NHS. The National Reporting and Learning System, the NHS Strategy and new format patient safety alerts, all managed by NHS Improvement, now ignore the majority of ‘known/wicked harms’ which have been the subject of patient safety alerts in the past and have now been archived." “Implementation of guidance in new Patient Safety Alerts can be delayed, for years in some cases. The Care Quality Commission that inspects NHS provider organisations also no longer appear to check that safeguards to major risks, recommended in patient safety alerts, have been implemented, or continue to be implemented, as part of their NHS inspections. Read full story Source: AvMA, 28 January 2020

Dozens of hospital trusts have failed to act on alerts warning that patients could be harmed on its wards, The Independent newspaper has revealed. Almost 50 NHS hospitals have missed key deadlines to make changes to keep patients safe – and now could face legal action. One hospital, Birmingham Women’s and Children’s Foundation Trust, has an alert that is more than five years past its deadline date and has still not been resolved. Now the Care Quality Commission (CQC) has warned it will be inspecting hospitals for their compliance with safety alerts and could take action against hospitals ignoring the deadlines. National bodies issue safety alerts to hospitals after patient deaths and serious incidents where a solution has been identified and action needs to be taken. Despite the system operating for almost 20 years, the NHS continues to see patient deaths and injuries from known and avoidable mistakes. NHS national director for safety Aidan Fowler has reorganised the system to send out fewer and simpler alerts with clear actions hospitals need to take, overseen by a new national committee. Last year the CQC made a recommendation to streamline and standardise safety alerts after it investigated why lessons were not being learnt. Professor Ted Baker, Chief Inspector of hospitals, said: “CQC fully supports the recent introduction of the new national patient safety alerts and we have committed to looking closely at how NHS trusts are implementing these safety alerts as part of our monitoring and inspection activity.” He stressed: “Failure to take the actions required under these alerts could lead to CQC taking regulatory action.” Read full story Source: The Independent, 30 December 2019