Patients at risk as NHS fails to respond to safety alerts

Action Against Medical Accidents says alerts are introduced to protect patients when things go wrong

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The NHS in Wales is putting patients at unnecessary risk by not implementing vital safety alerts according to a leading patients' safety charity.

Action Against Medical Accidents says that despite significant improvements in the past year, all seven Welsh health boards are missing deadlines.

The alerts introduce procedures to minimise risks to patients whose treatment has repeatedly gone wrong.

The charity had particular concerns about two health boards.

Alerts issued by the National Patient Safety Agency, a UK health watchdog, include:

  • procedures to minimise the risks of giving a patient the wrong blood during transfusion
  • promoting the safer use of injectable medicines
  • preventing deaths from incorrect doses of medicines.

Each alert has a deadline for its implementation.

Start Quote

It is possible that some patients may have suffered harm or even died needlessly as a result of alerts not being complied with”

End Quote Action against Medical Accidents

The total number of alerts outstanding across Wales reduced from 140 to 61 during the past year - a drop of almost 60%.

Every health board has seen an improvement in their rates.

However, Action Against Medical Accidents found some of Wales' health boards had not fully complied with certain alerts even though the deadline for implementation was more than five years ago.

The worst rate of compliance was at Hywel Dda Local Health Board, covering Carmarthenshire, Ceredigion and Pembrokeshire, which had not fully implemented 23 of the alerts by the deadlines.

In response, a spokesman said: "Hywel Dda Health Board takes compliance with patient safety alerts very seriously and has undertaken a review of accountability and responsibility to improve its response.

"As a relatively new organisation we also made the decision to review and revalidate compliance against patient safety alerts dating back to 2002 and believe this good practice will place us in a confident position in terms of compliance moving forward.

"We'd wish to assure our patients that compliance is closely monitored and reported to the health board's quality and safety committee."

Cathy O'Sullivan, acting director of the board of Community Health Councils in Wales, said it was "inexcusable".

"I don't believe that any patient safety alert should be outstanding, it should be completed by the deadline to ensure that we don't have incidents or accidents for patients," she added.

The report said the performance of Betsi Cadwaldr University Health Board, which runs health and hospital services across north Wales, was "also of particular concern", with 15 alerts outstanding past their deadlines.

Betsi Cadwaldr health board told BBC Wales that it would be inappropriate to comment until it had seen and considered the report in full.

Two health boards, Abertawe Bro Morgannwg (which covers Swansea, Bridgend and Neath Port Talbot) and Aneurin Bevan (which is responsible for the former Gwent area), reduced the number of outstanding alerts to just four each, the report found.

It concluded: "Whilst there has been significant and welcome improvement in compliance with patient safety alerts, it is very concerning that Hywel Dda and Betsi Cadwaldr health boards still have so many alerts outstanding, some of which are years past the deadline for completion, and that no single health board is fully compliant.

Outstanding patient safety alerts by health board area 2013 2012

Action against Medical Accidents

Abertawe Bro Morgannwg

4

16

Aneurin Bevan

4

11

Betsi Cadwaladr

15

34

Cardiff and Vale

5

12

Cwm Taf

8

25

Hywel Dda

23

27

Powys Teaching Health Board

2

17

"According to Standards for Health Services in Wales there should be 100% compliance. Patients are being left at unnecessary risk.

"It is possible that some patients may have suffered harm or even died needlessly as a result of alerts not being complied with."

The report suggests two health boards - Aneurin Bevan and Betsi Cadwaladr - have failed to fully implement procedures designed to reduce the risk of giving patients the wrong blood transfusion, despite the deadline for its implementation passing in May 2007.

Only three boards - Cardiff and Vale, Cwm Taf (covering the south east Wales valleys) and Powys - had completed actions on an alert designed to improve the safe administration of oxygen.

The deadline for completion of this alert was March 2010.

And three health boards - Aneurin Bevan, Cwm Taf and Hywel Dda - had yet to complete actions to prevent deaths from giving patients an incorrect dose of medicines, missing its November 2011 deadline.

Action Against Medical Accidents has called for an urgent review in the way patient safety is regulated in Wales.

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We continue to monitor this data across health boards and have set up a group to look at particular areas of concern”

End Quote Welsh government

It claims Health Inspectorate Wales (HIW) could not provide it with evidence that it had taken action to ensure compliance with patient safety alerts.

It said: "Health Inspectorate Wales appears to have ignored our previous reports and failed to protect patients' safety by ensuring patient safety alerts are complied with.

"This is a serious dereliction of duty."

The report also accused HIW and the Welsh government of failing to take the issue of non-compliance seriously and said the health minister had refused a meeting to discuss the issues.

Mandy Collins, deputy chief executive of Healthcare Inspectorate Wales, said elements of criticism were "justified".

She said: "I think we failed to properly respond to an FOI (freedom of information) request where we were given an opportunity to give a fuller picture in what we do in relation to patient safety alerts. There's a much better story for HIW to have told and, as I said, we missed that opportunity."

Ms Collins said every clinician had a "responsibility" to keep up to date and make themselves aware of patient safety alerts.

"Boards have a responsibility to make sure their organisations are fit for purpose and that involves making sure your services are safe and are complying with guidance, such as safety alerts," she added.

A Welsh government spokesperson said: "We welcome scrutiny of patient safety - this is a matter we take very seriously.

"While it is encouraging that NHS organisations have made major improvements to compliance on patient safety alerts, more still needs to be done to achieve full compliance.

"We continue to monitor this data across health boards and have set up a group to look at particular areas of concern.

"We have made it clear we expect all organisations to make further improvements in the interests of patient safety and quality of services."

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