Another disturbing report on Lewisham Hospital

A new and deeply disturbing piece of data has been released to the public thanks to the charity Action against Medical Accidents(AvMA), who with a Freedom of Information request put to the Department for Health unearthed the list of NHS Hospitals and Trusts that fail to fully comply with the Alert system of the National Patient Safety Agency(NPSA), an NHS office set up 8 years ago to analyze identified cases of medical blunders (official figures say over 3,500 people die each year for medical blunders, but independent experts say the true figure could be 25,000) and send out alerts to NHS Hospitals and Primary Care Trusts to prevent the same mistakes being repeated.

These alerts compel Hospitals and PCTs to act on the alerts and communicate back to the NPSA by a given deadline.
There have been 53 such alerts issued by December last year and astonishingly Lewisham Hospital NHS Trust failed to return a report of compliance for 31 of them, Lewisham PCT for 30 of them.

Nationally speaking Lewisham Hospital is the second worst offender and Lewisham PCT is the fourth (Greenwhich PCT is also joint second with also 31).

This is the second time in only three months that Lewisham Hospital is singled out for poor performance after it scored again 3rd from the bottom in Britain, again for patients’ safety, in the Dr Foster’s Hospital Guide 2009.

The News Shopper enquired with Lewisham Hospital and a spokesperson gave a very poor comment:

“Our Trust does not sign off the alert as complete until all components are fully investigated and assurance has been given that any relevant changes to practice or equipment have been made.

“This demonstrates a high level of attention to patient safety issues internally.

“However, we acknowledge that the hospital has fallen behind on reporting our compliance to the national database.”

And this is what Lewisham Hospital said instead to BBC File on 4 (link, mp3 18Mb) broadcast on Mondy 16th February:

“We acknowledge that the hospital has fallen behind on reporting our compliance to the National Database, the Trust is channelling more administrative and clerical support to the reporting system with which we must comply.”

One wonders, is it because, as they said to the BBC, they lack clerical staff to fill forms to send to the NPSA or is it because, as they said to the News Shopper, they comply so accurately with alerts that it takes them forever?

I actually imagine that these forms would be reports by practitioners, those that make the changes, not clerical staff, who else could say if the medical working practice had changed? I really think that what said to the BBC is a bit of PR nonsense.
And I am also greatly unconvinced that this is sign of a “high level of attention to patient safety issues” as said to the News Shopper. If anything it shows that they are slow to respond.
These alerts can save lives, to act on them quickly is important, that’s why they’re called alerts at all.

The Patient Safety Report tells us that alerts are only issued on evidence that the identified malpractices:

(a) are a serious threat to patient safety, usually based on repeated loss of life or damage to health

(b) can be addressed through practical actions, which are evidence based.

Information about which patient safety issues meet these criteria may come to the National Patient Safety Agency as a result of reports of incidents to its National Reporting and Learning System, or through other reports or evidence given to or gathered by it. Issues are carefully assessed for seriousness and the practicality of addressing them before it is decided to issue a patient safety alert on the subject. There is consultation with experts on both the need for an alert and the content, including the “required actions” which the alert asks recipients to make, and a realistic deadline for NHS trusts to complete the required actions.

The report includes the full list of flaunted alerts and the first one on record where Lewisham Hospital failed to report about implementation goes back to June 2004, 30 more followed.
There’s obviously something that needs change. Lewisham Council has some powers of scrutiny over this through the Healthier Communities Select Committee, and I really look forward to hear what they’ll do about it.

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