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The complaints included in the report are not thematic or related to a specific incident or body. Instead, these new annual Ombudsman Casework Reports will share some of the most significant findings from cases completed over the year, including complaints against: NHS in England Mental Health Care. The report offers valuable lessons about the importance of good complaint handling and how complaints can be used to drive improvements.

I used to work for the World Health Organization (WHO) helping to establish its patient safety programme over 20 years ago. Last week I was invited back to attend a three day WHO meeting on behalf of Patient Safety Learning to contribute to the development of its Global Patient Safety Action Plan for 2020-2030. Heading into this event, I had several key questions at the front of my mind: What have we learned about patient safety in the last twenty years? Why does harm remain so persistent? What impact has the global commitment to patient safety had in reducing harm? What approaches to patient safety are having the most impact? How can we be more effective share learning for safer care? A truly global problem This event took place within the context of the resolution of World Health Assembly (the decision-making body of WHO which is attended by delegations from all member states) in May 2019. This WHA resolution agreed to address global patient safety in a concerted manner. The meeting last week was to take this forward by developing a Global Patient Safety Action Plan between member states and the WHO to reduce unsafe care. In the introductory speeches the huge scale of the problem was set out: WHO considers that unsafe care is one of the 10 leading causes of death and disability worldwide. There are 134 million adverse events in hospitals in low and middle income countries, resulting in 2.6 million deaths annually. 1 in every 10 patients are harmed while receiving hospital care in high income countries. In addition to the shocking human cost, it was noted that patient safety incidents also serve to erode trust in healthcare and come with a major economic penalty – with it being estimated that nearly 15% of all health expenditure is attributed to patient safety failures annually, running into a trillions of dollars each year. Maintaining momentum Sir Liam Donaldson (WHO Envoy for Patient Safety) outlined in his introductory comments at this event the importance of maintaining momentum from the WHA resolution to tackle the issue patient safety in a global movement for change. He talked about his decision to become a doctor as a decision of the heart. As his career developed into leadership roles in the UK and at WHO, his head often ruled his heart but now he thinks it’s the heart that should drive us and our ambition to reduce harm. He also highlighted six current power blocks are not doing enough to improve safety and that need to be engaged and motivated to achieve change: Designing of health systems - to date there is not much evidence that systems are being designed for safety Health leaders - they are currently not using their power to lead for reduced harm Educational institutions - we need quicker developments to train staff Research community - there are questions as to whether patient safety research has led to sustainable reduction in risk Data and information - he questioned how effectively this has been employed to improve patient safety Industry - he noted the need for more action on this front, citing the example of the pharmaceutical industry on medication packaging and labeling and the need for more action by the medical devices industry. Implementing the Global Patient Safety Action Plan Dr Neelam Dhingra-Kumar (Coordinator for Patient Safety and Risk Management at the WHO) gave a presentation on the initial plans to implement a Global Patient Safety Action Plan. In this she set out the intention to set guiding principles and strategic objectives at a global level which could then be developed into actions at a country level, with the results subsequently informing SMART (Specific, Measurable, Achievable, Realistic, Time-Orientated) global patient safety goals. You can view her full presentation on the hub. A shared vision for patient safety The morning of the first day had contribution from global leaders on their vision for patient safety, from a patient and family perspective, from a patient safety experts, from a Ministry of Health representative and a list of proposed statements for vision, goals and guiding principles. At the very start of this session was… Patient engagement for patient safety Sir Liam Donaldson noted the important role that patients play in highlighting instances of unsafe care and noted that often ‘patients are not empowered to prevent their own harm’. Sue Sheridan (Co-founder of Parents of Infants and Children with Kernicterus (PICK) and the former lead of the WHO Patients for Patient Safety programme) developed on this theme, emphasising the importance of viewing patient safety through the lens of patients and families. She noted that they had a key role to play in making change happen and co-producing safer healthcare systems. Sue identified some common threads required for co-production of safer healthcare: Developing a core of diverse skilled family members who are willing to be partners in this work. Growing and incentivising creative and passionate healthcare leaders in patient engagement in quality improvement, research and policy. The importance of embedding patients in governance, strategic priorities and with funded programmes. The need for capacity building skills for patients (to inform and influence) and for professionals (to effectively partner with patients). Hard-wiring budgets so that there are the funds to enable this work. Systematically review outcomes. Develop a repository of co-production best practice. Sue highlighted that for patients and civil society to have a powerful voice, they must be supported with the appropriate tools and training and that institutions must embrace social movement with courageous leaders to co-produce safe care with patients. Key themes of patient safety implementation The remainder of the day was devoted to presentations on the key themes of implementation. I have listed these below and have selected a few of the topical areas to talk about in more detail that in my view, represented a new or strengthened perspective. Theme 1: Safety in patient care, clinical processes and use of medical products and devices. Theme 2: Patient safety policy and priorities. For the first time, patient safety has been included on the G20 agenda. Dr Abdulelah Alhawsawi (Director General at the Saudi Patient Safety Center) outlined the important role that the G20 can play in provide leadership on a global level for patient safety. In doing this he outlined the core features of the G20 Global Patient Safety Framework that is currently being developed: Patient Safety Culture. Resilience - recognising that all clinicians have harmed, and that healthcare is complex and the need for Human factors to be employed to address systems problems. Advocacy - everyone knows about global climate change, but people have not heard about the global patient safety challenge. This must change and we must advocate for this change. Information asymmetry – the importance of effective patient and family empowerment and real co-production with patients, making sure that they have the right tools to do this. Collective wisdom and learning – the importance of using data and effective means of measurement. Theme 3: Leadership and patient safety culture. Theme 4: Patient safety education and training. Theme 5: Human factors capability and capacity Dr Huda Amer Al-Katheeri (Director of Strategic Planning and Performance Development in Qatar) and Dr Kathleen Mosier (President of the International Ergonomics Association) gave a presentation on the role of Human factors/ergonomics in healthcare. In this they illustrated how poor Human factors is a healthcare in a consistent feature among patient safety failures, with systems often poorly designed and not tailored to the context/people involved. They outlined how Human factors can be integrated make healthcare systems more resilient for patient safety and the need to building these skills among workforce and enable greater participation. You can view their full presentation on the hub. Theme 6: Measurement, reporting, learning and surveillance. Theme 7: Patient safety research and innovation. Theme 8: Global Patient Safety Challenges. Theme 9: Patient engagement and empowerment. Theme 10: Patient safety in an era of universal health coverage. Theme 11: Developing networks and partnerships. Theme 12: WASH – Water, sanitation and hygiene, infection prevention and control. Coming up in part 2… In part 2 of the blog next week, I’ll talk about the discussions that took place on the second and third days of the event, highlighting the key issues that came up in the plenary session and reflecting on how this work should be taken forward.

I am an avid fan of the show, Silent Witness; pathologists trying to find out how someone was killed just from the body. The deceased is the only witness to what actually happened. So, by looking at the surroundings is the only way of determining what might have happened. I also love watching 24 Hours in Police Custody. This is where they interview the person directly involved in the incident, the people around the time of the incident and the person who potentially did the crime: questioning, piecing together exactly what happened using statements, CCTV footage, verbal accounts of everyone involved. The art and science of investigation is clear. The experience and knowledge of the investigators is quite remarkable. Investigation in healthcare doesn’t seem to work like this. I am a newly qualified nurse. I have been qualified just over a year now. I reported my first Datix last month. I took over the care of a patient from a colleague. I was coming on to a night shift. My patient looked very unwell. I took his observations. He was scoring a 9 on the NEWS2. I put a medical emergency call out. Everyone came, they got him a bit better. They decided he was not going to do well as he was frail and had many comorbidities, they decided to keep him on the ward and if he deteriorated further, he was for palliation. I was pleased I had a plan for him, but I noticed that he didn’t have any observations taken for over 12 hours previously. So, I reported it as a Datix. I marked it as a serious incident. I was worried when I reported it as I didn’t know what to expect. When would someone from the investigation team come and see me? Would I have to write a statement? When would I get interviewed? Will I get into trouble? I waited. The patient passed away peacefully. I forgot all about the report I had made. Six weeks later I received an email. The investigation had taken place. But I wasn’t included. No one had asked me how I had found the problem, the circumstances around the problem or even asked me to be involved. Why? I’m not trained in investigation, but surely being directly involved in an incident I would be asked what had happened and be included in their investigation? The email I received was to inform me of the outcome. ‘’Lessons learnt - Always follow the policies regarding the observation, statement taken from staff involved, practice educator involved with training.’’ I didn’t give a statement. The member of staff who didn’t do the observations made a statement, but not me. The investigation was also ‘downgraded’. What does it take to be a serious incident? This man had no observations for over 12 hours while unwell in hospital. He deteriorated and it wasn’t recognised. I think this is serious. Have others who have worked in healthcare become immune to the seriousness of incidents? As for the lessons learned; what are these lessons? Telling people to do tasks isn’t good enough. I can’t help thinking that healthcare hasn’t got this process right. Is this the same for other hospitals?

The 2015 Montgomery ruling created practical implications for how clinicians obtain consent and support patients to make decisions about their healthcare. The implication of the Montgomery ruling is that healthcare professionals must: clearly outline the recommended management strategies and procedures to their patient, including the risks and implications of potential treatment options discuss any alternative treatments discuss the consequences of not performing any treatment or intervention ensure patients have access to high-quality information to aid their decision-making give patients adequate time to reflect before making a decision check patients have fully understood their options and the implications document the above process in the patient’s record.

Watch Professor John Radford's interview with Sky News, explaining the importance of research at The Christie:

The report documents concerns about the lack of a properly independent investigation system, unlike deaths in prison and police custody which are independently investigated pre-inquest, and the consistent failure by most NHS Trusts to ensure the meaningful involvement of families in investigations. Ultimately, it highlights the lack of effective public scrutiny of deaths in mental health detention that frustrates the ability of NHS organisations to learn and make fundamental changes to policy and practice to protect mental health in-patients and prevent further fatalities and argues for urgent change to policy and practice.

The report argues for a fundamental rethink about the use of prison and calls for a political boldness to implement evidence-based change. The vulnerabilities of young prisoners have been well documented by countless research, investigations and inquest findings, yet they continue to be sent to unsafe environments, with scarce resources and staff untrained to deal with their needs. Based on INQUEST's specialist casework with the families of the prisoners who died, the report found that: 83% were classified as “self-inflicted”. The highest number of deaths occurred in HMYOI Glen Parva (six) and HMP Chelmsford (four). A further casework sample of 47 young and child deaths also found that: 30% of those who died were care leavers or had suffered some kind of family breakdown which required them to live outside of their immediate family home. 70% had mental health issues and 49% had self-harmed previously. A critical concern is that prison establishments have not learned lessons from previous deaths in prisons; too many deaths occur because the same mistakes are made time and again. In the light of these concerns, this report considers the implications and reasons behind prison deaths since 2011. Lastly, the report stresses the need for new thinking and new strategies if such deaths are to be avoided in the future.