The authors suggest that not enough is being done by the NHSLA to collate data in order to reduce future human and financial cost. The NHSLA holds a large amount of information, such as expert reports and counsels’ advices, which are costly to obtain and should be fed back into the system to reduce the chance of incidents being repeated, they claim.

The authors also question which NHS body is best placed to feed information from cases which have resulted in payment of damages back to clinicians, concluding that this is a role which might be expected of the NHSLA.

Christian said: “It is extremely frustrating, as a clinical negligence professional, to be faced by clients and their families who have been harmed by medical errors which you have seen happen before.  One of the driving factors of most patients who make a claim is to ensure it does not happen to anyone else…

“There needs to be some trend analysis from the NHSLA so we can find out if lessons are being learned from the claims brought and there needs to be reassurance that damages are not simply paid out case by case, with no wider analysis of whether the same issues are occurring within a particular Trust, with a particular surgeon or within a particular field of medicine.”

The authors conclude that the responsibility rests with all involved in the litigation system, including solicitors. They suggest a number of recommendations including a unified categorisation system to make it possible to track an incident from occurrence through to conclusion.

In Learning lessons from claims,² NHSLA risk management director Alison Bartholomew argues that the Authority has done much to promote learning from claims and describes various ways in which information on the liability claims managed by the Authority is used for risk management purposes to contribute to improvements in safety in the NHS.

Her paper asserts that the Authority has built on an established practice whereby solicitors on its clinical panel now provide a separate risk management report on all new clinical claims where they are instructed.  Each organisation is expected to consider the reports on their own claims and determine whether any further action to improve patient safety is indicated and, if so, take the necessary action, she claims.

Whilst acknowledging that lessons can be learned from claims to add to the safety agenda, Bartholomew suggests that relying on NHSLA claims to drive change in isolation could be misleading as these represent only a very small proportion of the number of adverse incidents that occur.

“Using the unique claims experience that it holds, the NHSLA has consistently sought to support healthcare organisations in improving their risk management practices,” she says.  “Based on the findings of assessments carried out against our own claims based standards, the NHSLA believes there is evidence to indicate that many healthcare organisations are using the lessons to be learned from their claims to improve the quality and safety of patient services.  However, there is a potential for us to do more.”

References

1 Ian Christian, Lindsay Gibb and Sarah Rowland.  Improving patient safety: How can the Legal Profession Help? Clin Risk 2011;17:81-4.

2 Alison Bartholomew.  Risk Management: Learning lessons from claims.  Clin Risk 2011;17:85-7.

Marie-Noelle Orzel, Patient Safety First’s deterioration intervention lead and Director of Nursing & Patient Care at Royal Devon & Exeter Foundation Trust says:  “Having clear data is central to being able to make and measure improvements to patients at risk of deterioration and cardiac arrest.  Trusts can determine how to improve safety for their patients by understanding where, when and what type of calls happen, whether they happen to particular patient groups and the reasons why a call is required.”

Patient Safety First provides a practical five-step approach for how trusts can monitor the types of cardiac arrest calls they have: The five steps to ‘Count your calls’ are:

• Where are your cardiac arrest calls or cardiac arrests coming from? This helps to identify potential ‘hotspots’ within the hospital that need targeted work.
• When are your cardiac arrest calls or cardiac arrests occurring? This will help to identify if there are certain days or times that are a specific problem, for example at night or at the weekend.
• Who are the individual patients needing cardiac arrest calls? Are there particular patient groups with high levels of calls or deaths associated with cardiac arrest? Identifying and collecting key  demographic data helps build a picture of any particular patient groups that are associated with calls.
• What happened? What type of call or cardiac arrest was it? What was the immediate outcome? This helps to identify the type of cardiac arrest call or type of cardiac arrest and provides data on the immediate outcome.
• Why was a cardiac arrest call required? This helps to determine whether a cardiac arrest call or cardiac arrest is predictable or unpredictable. Potentially predictable calls can be further classified as preventable or unpreventable.

Patient Safety First is encouraging trusts to take advantage of the range of online resources and tools designed to help them make improvements at a local level – www.patientsafetyfirst.nhs.uk.

‘Count your calls’  is the first of four Patient Safety First focus weeks that will provide trusts with an opportunity to explore their patient safety issues and join online discussions with experts.

The focus weeks include:

• 18^th January – Focus on Deterioration : ‘Count your calls’
• 1^st February – Focus on Human Factors in healthcare
• 1^st March – Focus on Ventilator care bundles: stories of improvement
• 8^th March – Focus on Insulin: ‘Testing a new care bundle for Insulin prescribing’.

For more information visit www.patientsafetyfirst.nhs.uk