Patients put at greater risk as hospital trusts ignore safety alerts
Two-thirds of NHS trusts are putting patients at unnecessary risk by failing to comply with safety alerts intended to reduce the risk of death or injury, an investigation has revealed. The alerts were issued by the National Patient Safety Agency (NPSA) in response to accidents in which patients were harmed, and they included instructions designed to minimise risks.
However, one in 14 trusts has not complied with ten or more of these alerts; two general hospital trusts – Worcestershire and York – have failed to comply with 20 alerts. In the case of one extra-urgent "rapid response" alert on oxygen safety in hospitals, 116 trusts which had failed to meet a compliance deadline of 29 March this year had still not taken action by June.
Another alert on the safe use of injectable medicines was issued with a deadline for compliance of 31 March 2008; by June 2010 – more than two years later – 67 trusts had still failed to comply with it.
These figures were obtained from the Department of Health by the charity, Action Against Medical Accidents (AvMA). They follow an earlier AvMA report in February, at which time the ministry wrote to all NHS trusts reminding them of their duty to respond to the alerts. Despite that reminder, AvMA's follow-up investigation found the situation little changed.
It criticised the Care Quality Commission (CQC), the independent health watchdog, for failing to pursue the trusts even when the situation was drawn to its attention. Peter Walsh, AvMA's chief executive, said: "It is quite shocking. But the thing that shocked us most was the complacent attitude. These are life and death issues. Our findings are very worrying."
Following a meeting with AvMA in June, the CQC wrote to those trusts with ten or more alerts still outstanding, demanding an explanation. The CQC said responses from the 29 trusts with the highest number of outstanding alerts showed that most had taken "significant action".
Ian Biggs, CQC's regional director for the South-west, said: "It is not the case that trusts are simply ignoring safety alerts. We are scrutinising all of the trusts' responses and if there is any cause for concern, we will take action and publish our findings."
The widow of one cancer patient who died as a result of a treatment blunder also criticised the CQC. Lisa Richards-Everton's husband, Paul Richards, died in July 2007 at Birmingham Heartlands Hospital. The 35-year-old was given a massive overdose of the drug amphotericin after staff confused two forms of the drug. The NPSA issued a rapid response alert to all hospitals two months later, requiring action by 1 October 2007. But Mrs Richards-Everton discovered that ten trusts had still not complied by February this year; three had still not complied by June.
She said: "I had a recent meeting with the CQC to find out what they are doing about the trusts not complying and, to my horror, I was told nothing had been done about the trusts who are not complying. I couldn't believe what I was hearing. Why are NPSA alerts issued if no one takes any notice?"
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