NHS is ‘losing its memory’ warns our new report on patient safety alerts

Published: 28 Jan 2020

AvMA has published its report “An organisation losing its memory? Patient safety alerts implementation, monitoring and regulation in England”.

The report has been authored by Dr David Cousins, former head of safe medication practice at the National Patient Safety Agency, NHS England and NHS Improvement, and reveals serious delays in NHS trusts implementing patient safety alerts which are one of the main ways in which the NHS seeks to prevent known patient safety risks harming or killing patients.

The report also identifies serious problems with the system of issuing patient safety alerts and monitoring compliance with them. Compliance with alerts issued under the now abolished National Patient Safety Agency and NHS England are no longer monitored – even though patient safety incidents continue to be reported to the NHS National Reporting and Learning System.

Report author David Cousins said:

“The NHS is losing it memory concerning preventable harms to patients. Important known risks to patient safety are being ignored by the NHS. The National Reporting and Learning System, the NHS Strategy and new format patient safety alerts, all managed by NHS Improvement, now ignore the majority of ‘known/wicked harms’ which have been the subject of patient safety alerts in the past and have now been archived.

“Implementation of guidance in new Patient Safety Alerts can be delayed, for years in some cases. The Care Quality Commission that inspects NHS provider organisations also no longer appear to check that safeguards to major risks, recommended in patient safety alerts, have been implemented, or continue to be implemented, as part of their NHS inspections.

“The number of patient safety alerts published each year by NHS Improvement is likely to continue to reduce at the same time as the number of preventable harms reported to the National Reporting and Learning Services increases every year. This new report describes these concerns in detail and recommends urgent action to address these risks to patients, before the NHS becomes an ‘organisation without a memory’”.

AvMA Chief Executive Peter Walsh said:

“We are grateful to David Cousins, a well-known patient safety expert, for this hard hitting and timely report. The recommendations should be acted upon by the NHS and Care Quality Commission. If it is serious about patient safety the NHS must be an organisation with a memory.”