Expert Calls For Patient Safety Reform

Lord Ara Darzi Has Called For Patient Safety To Be A Priority For The NHS


Lord Ara Darzi, director of the Institute of Global Health Innovation, wants patient safety to be a priority for the government in the coming months.

Writing in the Guardian, the former Labour health minister said that a number of "never events" had shown the need for change across the NHS.

In one case the politician and health advocate referenced, London Symphony Orchestra musician Maurice Murphy died after a nasogastric tube was passed through his nose into his lung instead of into his stomach.

The 30-year orchestra veteran was being treated in a London NHS hospital for a liver problem, but when a junior nurse questioned whether the tube had been put in the right place, a doctor reportedly said: "You don't have the brain to remember that I told you to start the feed. The tube is in the right position."

This, according to Lord Darzi, is a clear example of why the NHS needs to reform and as part of his role in the Institute of Global Health Innovation, he is backing the creation of 15 patient safety experts who will cover every region in the UK and ensure that all incidents where errors are made are investigated.

But Lord Darzi believes legislative changes on the horizon will improve care across the country.

"From next April, all NHS trusts will be mandated to investigate deaths in their hospitals in a standardised way by specially trained consultants who will be required to judge what proportion had a problem with their care and were avoidable," he wrote.

"These investigations will be subject to independent review by a central panel of trained doctors who will provide a national snapshot of the level of avoidable deaths in our hospitals."

Preventing never events remains a top priority in the UK, but there are still around 300 per year across NHS hospitals.

The majority of these involve swabs, gloves or other surgical instruments being left inside patients after operations, with 123 of these types of cases seen last year.

Expert Opinion
We see numerous cases which are so similar to those referenced by Lord Darzi, where patients have suffered serious or fatal injuries as a result of problems in care which could and should have been avoided.

"Patient safety should always be the fundamental focus of the NHS and this needs to be enforced in the right manner, with staff being given the necessary standards of training and support in order to do their jobs and provide care in the best possible way.

"It is also absolutely imperative that lessons are learned from any issues which do arise, as this will at least ensure that the NHS can take steps forward and improve standards where possible. It is unacceptable that patients lost their lives as a result of avoidable issues and this needs to change."
Mandy Luckman, Partner