Cambridge

The shocking catalogue of errors causing harm to NHS patients in Cambridgeshire

Health trusts in Cambridgeshire were responsible for more than 360 “serious incidents” involving patients last year, a report claims.

Data obtained under Freedom of Information requests by medical negligence solicitors Blackwater Law has revealed 102 incidents were recorded at the Cambridge University Hospitals NHS Foundation Trust – which runs Addenbrooke’s – in the 2016/17 financial year.

Serious incidents are defined as "adverse events and medical errors occurring in the NHS that affect patient care, including avoidable events causing serious harm, serious injury and death to patients", Blackwater Law says.

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They include failure to treat patients promptly and effectively, including on maternity wards, and also incidents where patients suffer accidents while in NHS care, such as trips and falls.

The Cambridge trust had 102 incidents in 2016/17, and its sister authority the Cambridgeshire and Peterborough NHS Foundation Trust, which deals with mental health, recorded 89.

In some cases, patients did not get prompt care

The East of England Ambulance trust racked up 95 incidents, most of them relating to care of patients, delays in getting to patients, and delays in transporting patients to hospital.

A total of 66 incidents took place in the North East Anglia Foundation Trust, but relatively low numbers were recorded at the Cambridgeshire Community Services and Papworth Hospital trusts – 5 and 7 respectively.

In all, the law firm requested data on 235 NHS trusts in England and Wales, and in all, more than 40,000 incidents were recorded.

More than 40,000 incidents were recorded in 2016/17

Which trusts had the most incidents?

The highest number of incidents took place at the Pennine Acute Hospitals NHS Trust in the Rochdale area (778), Betsi Cadwaladr University Health Board in Wales (668) and Portsmouth Hospitals NHS Trust (389).

Jason Brady, partner and medical negligence solicitor at Blackwater Law, said: "It is truly concerning to learn that the number of serious incidents being recorded by NHS trusts across England and Wales stands at such a significant figure.

"It is crucial to remember that these are not just statistics. Each of these incidents is a patient and a family that may be suffering, potentially unnecessarily, with possible long-term implications for their future and quality of life."

Below standard care, treatment delays and falls are among the most common incidents

This is what the Addenbooke’s trust says in response to the report:

"Safety is our absolute priority and we are proud to be below the national average for serious incidents, despite the fact we treated well over two million patients between 2015 and 2017 and are a very large, acute trust. These incidents, which include trips, slips and falls involving patients and staff, are diligently recorded and reviewed so that learning from them can be captured and implemented as soon as possible.

"The figures are not new and form part of regularly updated data available for public view on the National Reporting and Learning System website. The NRLS was set up in 2003 and information supplied nationally is analysed to identify hazards, risks and opportunities to continuously improve the safety of patient care.”

The Cambridgeshire and Peterborough NHS Foundation Trust’s response is:

"It is important that these figures are seen in context as Cambridgeshire and Peterborough NHS Foundation Trust serves a population of more than one million people.

"We take all incidents extremely seriously and investigate them all to see what lessons can be learned, what support can be offered to patients, families and staff affected, and how practice can be improved in the future.

Breakdown of serious incidents in mental health trusts

"CPFT provides mental health services, community healthcare for older people and those with long-term conditions, children’s services in Peterborough, and social care services.

"The nature of our work means our dedicated staff provide care and help for people often when they are at their most vulnerable.

"The term ‘serious incident’ is wide-ranging and can include any incident relating to a patient’s care. It can also include staff who are harmed while carrying out their duties.

"Overall, our safety record is in line with the national picture and we continue to do everything we can to ensure the safety of those in our care, and colleagues who are employed by the trust, remains our highest priority.”

More than half the incidents relate to patient care, and delays in treatment

Here’s what the East of England Ambulance service says:

"The way we report serious incidents (SIs) has changed for some time, as we have been reporting near-miss SIs in line with the NHS SI Framework, which can be an incident that had the potential to cause harm but didn’t.

"The trust is developing a culture of learning from all incidents and these include near misses where no harm to patients have been identified. NHS Improvement suggests we should encourage healthcare staff to record all patient safety incidents, whether they result in harm or not.

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"With this in mind, of the 95 serious incidents reported in 2016/2017, just 44 per cent would previously have been reported as a serious incident, which is a decrease when compared to the same statistics in the previous financial year where 71 per cent of incidents reported would have been considered a serious incident.”

Tracy Nicholls, deputy director of clinical quality, said: "A dedicated centralised team in conjunction with our leadership teams monitor, investigate and identify areas of learning from all SIs, even if no harm was caused.

Nearly 100 incidents related to the East of England Ambulance trust

"As a service, we have a robust system in place to constantly review trends and themes to enable us to make any identified necessary improvements and reduce any harm to patients where possible. This system has been tested by our regulators and no issues have been found with our stringent processes.

"We have also seen a sustained increase in our staff reporting such incidents, which is positively welcomed as we continue to focus on bettering our service. Our focus has been on quality improvement and over the past two years we’ve seen a reduction in harm to patients as a result in this change of approach.”

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