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Hannah Blackwell considers current proposals to try and ensure patients safety lessons are learnt from litigated clinical negligence cases.
The patient safety charity, Action Against Medical Accidents (AvMA), has submitted a proposal to ministers designed to ensure there is always a review of litigated clinical negligence cases so that lessons can be learnt from those cases and safety measures implemented to try and prevent similar events occurring again.
As an independent Charity, AvMA specialise in providing independent advice and support for patients and their families who have been affected by a lack of patient safety. AvMA provide advice through a helpline as well as offering a more intensive case worker, and an inquest support service. AvMA are therefore well placed to have insight into the types of issues that go wrong with medical treatment and the experience of patients and their families following such incidents.
AvMA believe that much more can be done to learn lessons for the improvement of patient safety from cases that have been the subject of litigation. From my experience of representing clients in medical negligence cases, I whole heartedly agree with this. Often clients come to us seeking compensation but also want to ensure that what has happened to them does not happen to anyone else. As a clinical negligence solicitor, I can only work towards seeking my client’s compensation and cannot guarantee them an apology or the reassurance that steps are being put in place to improve patient safety to ensure what happened to them does not happen to anyone else, and this can be frustrating.
AvMA highlight the fact that issues giving rise to failings in healthcare, including negligence claims, frequently repeat themselves indicating that not enough is being done to address the cause of these clinical failings or to learn lessons from them. Again, I would agree with this as my colleagues and I often see similar patterns of failings in care across the cases in which we are instructed.
The proposals put forward by AvMA include:
1. Care providers should be obliged to demonstrate that they have recognised and acted on the lessons learned from litigation.
2. A “responsible person” at the healthcare provider should prepare a document that would be known as a “patient safety letter” setting out the breach of duty or clinical failings identified.
3. The patient safety letter should have three functions:
As I mentioned earlier, clients will often say to me at the outset of the case that a major motivation in bringing a clinical negligence case is to ensure that what happened to them does not happen to someone else. I have noted a real variation in the way NHS Trusts responds to patient safety issues. Some Trusts will include in their ‘Root Cause Analysis’ reports steps they intend to implement to try to avoid the incidents being repeated. However, in many of the cases I am instructed on, it remains unknown to both myself and my client whether the healthcare provider has taken on board learning points from the cases and implemented steps to ensure any failings in those cases are not repeated.
I therefore support the proposals AvMA have presented to ministers as it would seem this would establish a culture in which lessons are learnt and steps put in place to try to prevent the poor treatment we see on cases being repeated. I shall therefore be following the ministers response to the proposal with interest.