21 Feb 2011

NHS trusts still failing on safety alerts

Trust hospitals and primary care trusts are still failing to comply with patient safety alerts despite a warning a year ago that doing so was mandatory, Channel 4 News learns.

NHS hospital trusts and primary care trusts are failing to comply with patient safety warnings (Getty)

In a report by the charity Action against Medical Accidents, they found that half of all trusts – 203 organisations – had failed to comply with at least one alert.

This figure was from a snapshot of England’s trusts taken on 20 January. It also found that 45 trusts had not complied with five or more alerts and five trusts had not complied with 10 or more alerts.

A patient safety alert is issued by the National Patient Safety Agency when it becomes aware that there is a problem that has repeatedly caused harm or killed patients.

Half of all NHS trusts have failed to comply with at least one patient safety alert.

The trusts are then given a set time to take action. The report claims that “many of the alerts which had not been complied with were years past the deadline for completion.”

Alerts ignored

AvMA’s chief executive Peter Walsh said that the alert called “Safer use of injectable medicines” had a deadline of 31 March, 2008. Nearly three years later, 26 trusts had still not complied. Yet, injecting a patient with the wrong dose of a drug or injecting into the wrong part of the body is one of the most common causes of “accidents” or “adverse incidents”.

Mr Walsh said: “This is one of the alerts which has the potential to save the most lives.”

This was highlighted by the case of David Gray, who died in February 2008 of a massive overdose of diamorphine administered by an out-of-hours GP from Germany. Alerts had been sent out to warn against carrying higher doses of diamorphine.

Mr Gray’s son, Rory, told Channel 4 News that he felt sickened when he learned that alerts had been issued and not implemented.

AvMA, which has produced three reports now on compliance with patient safety alerts, said there had been a 50 per cent decrease over the past six month in the number of alerts not being complied with, which they applauded. But they said that still left 654 alerts ignored.

Although progress has been made, much more needs to be done. Department of Health

“All alerts are meant to be complied by all trusts by the given deadline,” Mr Walsh said.

The Department of Health said in a statement: “Our modernisation plans bring a new level of transparency and accountability in the NHS. We believe a transparent NHS is a safer NHS. That’s why this Government published this information that was not previously in the public domain.

“Although progress has been made, much more needs to be done across the system. Our proposals would, for the first time, introduce a legal duty for the NHS and the whole care system to improve continuously the quality of patient care in the areas of effectiveness, safety, and – most importantly – patient experience.

“On safety alerts specifically, we expect NHS Trusts to comply with safety alerts, including recording that action has been taken in order to minimise any risks in the future.”