Fieldfisher are proud to lend their support to Action against Medical Accidents (AvMA) and their campaign to ensure issues of patient safety are addressed in litigated cases.
When clients first come to see me, one of the questions that they frequently ask is "Will lessons be learnt from what happened to me?" I will typically answer "hopefully" but explain that unfortunately we see the same types of errors occurring time and time again, and questions really have to be asked as to whether lessons are in fact being learned.
Sometimes I will see repeated errors happening at the same hospital. Sometimes I will see similar instances of negligence occurring in two different hospitals in different parts of the countries. Regardless of where the negligent act occurred, repeated errors should simply not take place. As Oscar Wilde said "To err once is human, to err twice is careless."
It is against this backdrop that AvMA, the independent charity that works for better patient safety and justice for patients when things go wrong in a healthcare setting, have decided that more needs to be done.
AvMA themselves comments as follows:
"AvMA has long believed that much more could be done to learn lessons for the improvement of patient safety from cases that have been the subject of litigation. We believe there is very limited evidence of this happening systematically. Whilst only a small minority of the people who come to AvMA for help turn to litigation, invariably when they do so, the desire to ensure that lessons are learnt and safety improved to prevent the same thing happening to someone else is high on their agenda. The fact that the issues giving rise to failings in health care, including negligence claims repeat themselves indicates that not enough is being done to address the causes of these clinical failings or to learn lessons from them, this includes legal claims."
AvMA's proposals include the following:
- Care providers should be obliged to demonstrate that they have recognised and acted on the lessons learned from litigation.
- Where any breach of duty or clinical failing has occurred, even if it does not result in an admission of liability or settlement, a Responsible Person must be obliged to prepare a reporting document, to be called a Patient Safety Letter, which sets out all of the breaches of duty and clinical failings identified.
- A Patient Safety Letter should have three functions. Firstly to set out the breaches of duty and clinical failings identified so these can be addressed by the care provider. Secondly, to challenge how robust the care provider's internal procedures have been in investigating such failings and whether they should have been identified earlier. Thirdly, and most importantly, the Patient Safety Letter should be sent to the injured party, be published and sent to relevant external organisations such as the Care Quality Commission, the relevant commissioner of the service, and NHS Improvement.
Time will tell if AvMA's plans are supported by other key bodies such as the NHSLA. It is interesting to note that within the recently published annual report by the NHSLA's Chief Executive, Helen Vernon, she herself comments:
"The key to reducing the growing costs of claims is learning from what goes wrong and supporting changes to prevent harm in the first place."
I could not have put it better myself.
By Mark Bowman, Partner
Contact Mark
If you or your loved one has suffered from medical negligence or a substandard level of care and would like to talk about making a claim, call Mark Bowman on:
- T: 0330 460 6794, or
- E: mark.bowman@fieldfisher.com
Alternatively
- You can speak to any member of the Fieldfisher Medical Negligence team on Freephone 0800 358 3848 or,
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