Page last updated at 23:12 GMT, Thursday, 2 July 2009 00:12 UK

Patient safety 'still threatened'

Wayne Jowett
Wayne Jowett was undergoing treatment for a form of leukaemia

Basic changes recommended after a cancer drug slip-up that killed a teenage boy have yet to be implemented, eight years after he died, MPs say.

The House of Commons Health Committee warns targets "too often" come before patient safety and highlights inaction on measures which could save lives.

Wayne Jowett died in 2001 after drugs were injected in his spine not a vein.

Changes to spinal needles to stop the same mistake happening again were drawn up, but have yet to be introduced.

"It is totally unacceptable that an identified and simple solution to a catastrophic problem should take so long to be put into practical use," the health committee wrote in their 100-page report on patient safety failings.

The MPs also suggested that a fear of litigation and a "blame culture" was preventing healthcare workers from being open when mistakes occurred.

The committee heard from one mother who said doctors continually changed their story about why her daughter had bled to death on the operating table.

Boards and senior management make patient safety top priority
Regular reviews of patients' case notes to check for negligence
Quick implementation of proven technologies
Ensure families always receive full, frank information
Introduction without delay of NHS Redress Scheme

The committee said it was appalled at the failure to introduce the NHS Redress Scheme, designed to encourage openness by removing the threat of lengthy and costly litigation, three years after parliament passed the necessary legislation.

As well as the distress it causes to patient and family, medical harm - from errors in medication to patients falling out of beds without bars - may be costing the NHS billions each year, according to estimates collected by the committee.

This sum includes millions paid out by the NHS Litigation Authority to settle clinical negligence claims, and potentially similar amounts to reverse the damage caused by medication errors.

'Not a priority'

But despite the costs, the Health Committee's annual report said there were NHS boards across the country who had simply "never considered patient safety at all".


The MPs cited the example of Mid-Staffordshire Trust as one where managers' pursuit of Foundation status - with all its accompanying benefits - meant patient safety was neglected in favour of meeting targets.

They criticised Monitor, the independent regulator, for taking at "face value the Trust's excuse that its poor mortality figures were a statistical anomaly", describing this as "wholly unacceptable".

The evidence suggests the extent of medical harm is substantial and that much is avoidable
Health Committee

The Trust hit the headlines in March after a separate regulator, the Healthcare Commission, uncovered stories of patients being denied food, water or medication as their operations were repeatedly cancelled amid a lack of staff.

The Healthcare Commission has subsequently been replaced by the Care Quality Commission (CQC).

The MPs said they had serious concerns about how the two bodies would work together and share responsibilities, noting there was "considerable potential for confusion, and possibly conflict".

Committee chairman Kevin Barron said after conducting his report he found it "difficult to say" that another scandal on the scale of those seen at Mid Staffordshire or Maidstone and Tunbridge Wells Trust, where 90 people died from a superbug, would not happen again.

A spokesperson from Monitor said: "The report has raised a number of questions for Monitor in relation to our assessment and authorisation of Mid Staffordshire NHS Foundation Trust and the need for clarity between bodies who have responsibility for managing and regulating the healthcare system."

The CQC added: "Monitor and the CQC recognise and respect the statutory responsibilities and independence of each other, but will wherever possible seek to collaborate and cooperate."

Roger Goss, of Patient Concern, said: "The failure to improve safety will in turn deter people from using the NHS."

And health minister Ann Keen said the recommendations would be carefully considered.

She added: "The vast majority of NHS patients experience good quality, safe and effective care and that we are one of the world leaders in the international drive to improve the safety of healthcare.

"However, we acknowledge there is more to do and will continue to strive to make services even safer."

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