Welcome to the latest edition of my blog series, Prioritising Patient Safety. This edition feels like a particularly significant one to share with you. We recently launched our new five-year strategy. I want to use this blog to show how it is already shaping the way we work - not just in how we handle complaints, but in how we use them to drive real change across the NHS.
Our strategy is built around three priorities: driving public service improvement, improving the user experience, and raising awareness and trust. You’ll see all three reflected in what I share below.
In this edition, I will:
- share news of an exciting new partnership with two medical schools in the north-west, and what it means for the future of the clinician-patient relationship
- provide an update on Andy’s case, which I first wrote about in my Winter blog, including the positive changes the Trust has made
- share a new case involving an avoidable death and the constructive way the Trust responded to our findings.
Using complaints to shape the next generation of doctors
Effective communication lies at the heart of the relationship between doctors and patients. When it works well, it builds trust and leads to better outcomes. When it breaks down, complaints arise and we see this again and again in our casework.
In some cases, we are seeing a lack of trust, rising expectations and defensive cultures that can fracture the relationship altogether. We also know that clinicians themselves are struggling. Burnout, stress, moral injury and vicarious trauma are taking a significant toll.
Our complaints data puts us in a unique position to help. The cases we investigate are real-life experiences and they can be powerful tools for learning. One of the most exciting ways we are putting this into practice is through a new partnership with two medical schools in the north-west, Edge Hill University and the University of Chester.
We want to support these schools in equipping future doctors with the skills to build strong relationships with patients, respond compassionately to concerns and resolve issues constructively. We hear from the medical schools that students are often excluded from conversations about complaints or difficult discussions with patients. This lack of exposure can create a disproportionate fear of complaints and leave students ill-prepared to handle them. We can help change that.
We are working with both schools to help shape their ‘spiral’ curriculum, which spans the full five years of a medical degree. We will work alongside tutors to build students’ knowledge and confidence in handling complaints throughout their training.
This summer, we are hosting two interns - one in their fourth year and one in their fifth year of medical school. They will spend time working with us to see the full path of a complaint: listening in when complainants speak to caseworkers, sitting with clinical advisers and observing mediation. We hope this will give them an insight that most medical students never get.
We are also hoping to work with a third-year student on a research project. This will look at awareness of the Ombudsman among their peers and track whether that changes as our collaboration with the schools develops.
Looking ahead, Edge Hill is hosting a conference this autumn, funded by a small grant, to showcase this work to medical educators. We hope it will attract interest from more medical schools across the country. We also plan to work with partners including the General Medical Council, Nursing and Midwifery Council, NHS England and the Royal Colleges to help scale this and encourage organisations to carry this learning through into doctors’ foundation years.
An update on Andy’s case
Some of you may remember Andy’s case from my winter blog. Andy had been admitted to hospital with a urinary tract infection and needed intravenous antibiotics. The Trust decided to prescribe oral antibiotics instead but these were not available at the hospital pharmacy. Andy received no treatment for the infection for over 30 hours. His condition deteriorated and he died. We found his death to be avoidable.
After closing our investigation, we met with the Trust to discuss our findings and the actions it had taken in response to our recommendations. It was a constructive meeting, and I’m pleased to share that the Trust has made significant changes. These include:
- transitioning to a new electronic prescribing system (WellSky), which has improved visibility of overdue medication and strengthened medication safety
- implementing elements of Martha’s Rule, including a daily patient wellbeing question and mechanisms to capture concerns from patients who may have difficulty communicating
- a forthcoming process allowing patients and families to request an internal review where concerns about deterioration are not being addressed, available 24 hours a day
- continued work on learning disability advocacy, with designated learning disability ambassadors, reasonable adjustment processes and a vulnerable patient steering group.
The Trust acknowledged that there are still areas to develop, particularly around sample visibility and communication between primary and secondary care. Nottingham Integrated Care Board has been engaged to support progress on this. While some differences of perspective remain on elements of the original case, it was clear that the Trust is genuinely committed to learning and improvement.
The Trust told us:
“The meeting was regarded as a constructive opportunity to achieve mutual understanding and to strengthen collaborative working arrangements going forward. The Trust remains fully committed to organisational learning and continuous improvement and appreciates the opportunity to discuss these matters in detail with you.”
Tom’s case: routine nursing checks and an avoidable death
I also want to share a more recent case involving Tom, whose death we found to be avoidable.
Tom was admitted to hospital with serious health problems, most notably severe breathing difficulties. He was heavily dependent on oxygen therapy at home and this continued during his hospital stay.
Tom’s wife visited him every day. On one occasion, she was asked to leave the room while nurses carried out routine checks and helped Tom with his daily needs. During these checks, as the nurses moved Tom, his oxygen supply became disconnected from the wall. The nurses did not notice. When Tom’s wife returned after more than five minutes, she found him in distress and struggling to breathe. Sadly, Tom’s condition deteriorated rapidly and he died.
The Trust conducted its own investigation and initially concluded that the oxygen disconnection had not contributed to his death. We disagreed. We were able to engage positively with the Trust to share our emerging views, and it responded constructively - immediately accepting our findings and recommendations.
The Trust said:
“We are intending to review the previous internal governance investigations of this case to identify how we can make sure we get things right first time in the future... I also very much appreciated your approach in this case to minimise distress to his wife. It was nice to be able to work together to resolve this case appropriately and sensitively.”
I want to encourage all organisations to engage with us in this way. As Tom’s case shows, when organisations are open to honest dialogue, it leads to better outcomes — for the organisation and for the people who raise concerns.
What's new in the world of patient safety
- We've published a new briefing which shares insights from senior leaders at NHS trusts across England on how they handle complaints, what complaints reveal and how they use that learning to make improvements.
- The Patients Association has published its latest Patient Experience report, highlighting how people are experiencing care across the NHS.
- Patient Safety Learning have started a newsletter, The Hub.
- NHS Resolution has recently published an evaluation of the Maternity (Perinatal) Incentive Scheme (MIS)
- HSSIB has published a report on patient safety in mental health settings