Is the NHS learning from its mistakes?

In early 2010 a new risk management initiative was introduced by the NHSLA to ensure that organisations are learning from their own claims and that the knowledge gained is shared.  The objective was to reduce the number and severity of incidents giving rise to claims in the NHS.  The Annual Review covering 2010/11 was published in March 2012.

Key facts

• Compensation totalling £792 million was paid under the CNST in 2010/2011
• 1,978 solicitors’ risk management reports on claims (SRMRC) were produced throughout February 2010 and March 2011 (albeit 8,655 claims of clinical negligence were received by the NHSLA)
• Specifically there were 310 SRMRC for maternity related claims
• Reports were sent to 272 healthcare organisations
• 28% of risk management issues were identified as a result of expert evidence being obtained
• Clinical negligence claims represent around 0.7% of the number of incidents reported to the National Patient Safety AgencyAround 50% of NHS organisations had fewer than five SRMRC, but 19 organisations had more than 20 SRMRC each.

Key Findings

• More than 1000 actions were taken by NHS organisations in response to the claims for which SRMRC were prepared, 62% of which were taken prior to receipt of the report and 38% taken after receipt of the report.
• The most common action taken by organisations as a whole related to policies and procedures, followed by training.
• Failure/Delay Diagnosis and Fail/Delay Treatment comprised 29% of all NHSLA claims cause codes.
• In over 100 of cases, no action had been taken by the organisations in response to the report with the main reasons being cited that actions were yet to be considered (56%) and actions had been considered but were yet to be implemented (13%). 
• When asked if they could provide evidence of the actions taken if required, 11% of organisations indicated that this would not be possible or failed to provide a response (the NHSLA is following up these organisations).
• For a number of organisations it was clear that a system for considering and learning from the SRMRC had not been established.
• Some organisations had to be given several opportunities to provide a response regarding the actions taken in relation to their SRMRC as part of the annual review.  Around 50% of organisations provided a response within the initial four week period – some took six months to respond despite reminders.

Moving Forward

Whilst it appears that much fewer SRMRCs were produced in 2010-11 than claims notified to the NHSLA, it must be remembered that not all claims notified would have a relevant incident date, or reach the stage of panel solicitors being instructed or expert reports being obtained.  However, it is important that SRMRCs are produced on all relevant cases. It is up to the individual Trust to action the points identified in the reports.  The Review suggests that some organisations are not fully appreciating the use/benefit of these reports and the risk management issues contained within them. 

For these reports to provide meaningful benefit to the organisation, it is important that where claims and risks teams work separately, good communication links exist and information is being shared with the appropriate people.

The review indicates that systems should be in place to monitor the implementation of all actions taken in response to incidents, complaints and claims, including the SRMRC, otherwise they may not be completed.  It is important that NHS bodies commit sufficient resources to permit this to happen.  Enhanced follow up for evidence of the reports being actioned may assist with this.   

The NHSLA considers the initiative to be an integral part of risk management and, in order to encourage more reports being produced, they have recently produced a new form to make the provision, collection, quality and analysis of data more efficient and effective.  The aim going forward is to ensure that the report is only produced when liability investigations have been completed.  

The NHSLA also intends to increase the focus on individual follow-up of organisations throughout the year, rather than via an annual review.  This is likely to place pressure for improvement on those organisations that consistently have more reports produced for them and where the same cause code crops up frequently.