Concerns over ‘Government’s failure’ to act on patient safety recommendations

By Storm Newton, Reporter22nd March 2024News EnglandCare Standards, Government / Politics, Hospitals, News England, NHS

The Government has failed to implement a number of recommendations from significant inquiries into major patient safety issues, years after they were agreed to, according to an independent panel.

The report, commissioned by the Health and Social Committee in the wake of the Lucy Letby case, voiced concerns about “delays to take real action”.

As part of its investigation, the panel selected recommendations from independent public inquiries and reviews that have been accepted by government since 2010.

These covered three broad policy areas – maternity safety and leadership, training of staff in health and social care, and culture of safety and whistleblowing – and were used to evaluate progress.

The recommendations on maternity care and leadership came from the 2013 report that followed a public inquiry into patient deaths at the Mid Staffordshire NHS Foundation Trust, as well as the 2015 report from the Morecambe Bay Investigation, which highlighted serious failings at the University Hospitals of Morecambe Bay NHS Foundation Trust leading to the deaths of mothers and babies.

The panel gave the Government a rating of “requires improvement” across the policy areas. One of the recommendations was rated good.

The report said that “despite good performance in some areas” the rating “partly reflects the length of time it has taken for the Government to make progress on fully implementing four of the recommendations which were accepted nine years ago, or longer”.

“Progress is imminent in several areas, which is reassuring, but we remain concerned about the time it has taken for real action to be taken,” it added.

The panel did recognise the impact the Covid-19 pandemic may have had on implementing recommendations.

Professor Dame Jane Dacre (pictured), chair of the expert panel, said: “Our evaluation has examined Government progress to implement recommendations made by an independent inquiry or review when there’s been a major incident involving patient safety.

“We’ve looked at recommendations made by significant inquiries, Morecambe Bay and Mid-Staffs, both involving tragic loss of life.

“Nine or more years have passed since these recommendations were accepted by the government of the day.

“We are concerned about delays to take real action to implement them and rate overall progress by the Government on this serious matter as requiring improvement.”

The report added the aim of using “evidence-based scrutiny” is to “feed back to those making promises so that they can assess whether their commitments – or in this case, the implementation of recommendations the Government has accepted – are on track to be met”.

Steve Brine, chairman of the Health and Social Committee, welcomed the report, which he said was “commissioned in the wake of the deep concern around the Letby case which gave rise to calls for another statutory inquiry”.

Letby was convicted of murdering seven babies and attempting to murder six others, with two attempts on one of her victims, at the Countess of Chester Hospital’s neonatal unit between June 2015 and June 2016.

She was sentenced to 14 whole life orders.

Senior judge Lady Justice Thirlwall is leading the inquiry into how the nurse was able to carry out murder and how the hospital handled concerns about her.

Mr Brine added: “Investigations into major failures in the NHS, like the Thirlwall Inquiry into Letby, are vital but it’s equally important to hold the Government and leaders of organisations responsible for actually implementing the recommendations that are made to improve patient safety.

“It was progress on a selection of such recommendations – each accepted by Government – that our independent experts assessed. It is therefore disturbing to hear of delays in fully implementing the majority of them.

“The Health and Social Care Committee has now launched its inquiry into leadership, performance and patient safety in the NHS. The work of the panel will provide valuable insights and an important foundation in support of our forthcoming public evidence sessions.”

Publication of the panel’s findings comes after NHS Whistleblowers, a group representing hundreds of current and former doctors, midwives and nurses, asked to contribute to the Lucy Letby inquiry.

They have instructed Hudgell Solicitors to represent them, arguing there is a need to look at problems across the entire health service, not just in one trust.

A spokesperson for the Department of Health and Social Care said patient safety was “paramount”, adding that it had “made significant progress to improve care, including publishing the first NHS Patient Safety Strategy”.

“We recently announced the first phase of Martha’s Rule which will give patients or family members in 100 NHS sites the right to a rapid review of their care if they are concerned their condition is worsening,” they said.

“We have also established an independent body to investigate and learn from serious patient safety incidents, and we have made progress in improving maternity services, reducing the stillbirth and neonatal death rate by 23% and 30% respectively since 2010.”