Increase in reports of patient safety cases at Walsall Manor Hospital trust

Walsall Healthcare NHS Trust recorded the incidents between October 1, 2019, and March 31, 2020.

It included 14 incidents which resulted in death

The 2,295 reported incidents represented an increase of 10 per cent compared to the same six-month period the previous year.

Patient safety incidents are defined as "any unintended or unexpected incident that could have or did lead to harm for one or more patients receiving NHS-funded healthcare". Each incident is recorded, along with the level of harm that was suffered by the patient as a result of the incident, ranging from no harm through to death.

The incidents encompass a broad spectrum of medical errors and events including misdiagnosis, incorrect treatment, surgical errors, procedural errors, medication errors and problems, patient administration errors as well as failure to prevent self-harming behaviour.

During the six-month period there were a total of 14 patient safety incidents that resulted in death recorded at the Walsall Healthcare NHS Trust – a sharp increase compared to only one death in the same period the previous year.

The new data has been analysed by medical negligence solicitors Blackwater Law. Jason Brady, partner and head of Blackwater Law, said: "It is a concern to see such a material increase in the number of patient safety incidents resulting in harm to patients, or even death.

"At Blackwater Law we see the consequences of these incidents and errors in medical care on patients and their loved ones, some of whom suffer life-changing injuries and illness as a result. We are contacted by suffering patients every day. It is important to remember that every number is a patient and a family.

Transparency

“We welcome the transparency of the NHS in reporting these incidents and it is hoped that lessons can be learnt from these. However, it is important that patients receive safe and effective medical care, given the huge implications it can have on patients when this does not happen. We hope the NHS can learn from the data and individual cases.

“The data relates to the period before the coronavirus pandemic gathered speed and lockdown was introduced."

Jenna Davies, director of governance at Walsall Healthcare NHS Trust, said: “As an organisation, Walsall Healthcare promotes and encourages incident reporting as it is just one of the ways that we keep services and patients safe. We have seen an increase in incident reporting over the last 12 months which is in line with a national increase in reporting of around 12 per cent. Being a high reporter is regarded as a positive approach in the NHS, and reporting is what keeps services and patients safe.

“The increase largely relates to incidents that are rated 0-2 (near miss to low harm) which is positive in terms of a healthy patient safety culture, although we continue to work with our teams to reduce these. The number of overall incidents that are rated as 3-5 (moderate to death) largely remains static and hasn’t seen an increase in line with the increase of the less serious incidents detailed above.

“We saw higher reporting of incidents during the winter months which related to falls and pressure ulcers and the trust has done a lot of work with staff, patients and the public to raise awareness and improve prevention. Two of these were incidents which met the serious incident criteria and were infection control-related.

"Reporting Serious Incidents is an essential part of delivering improved services - we have good processes and a high reporting culture where our staff feel supported and our focus is on patient safety and continuous improvement. Our priority is patient care, so all incidents are taken seriously and a root cause analysis investigation is undertaken so that we can learn from the incident and improve practice.”