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More than 40,000 serious incidents have been recorded by NHS trusts and public health boards in England and Wales in the last two years. [Photo: Bigstock]

“Serious incidents” in UK hospitals on the rise

More than 40,000 “serious incidents” – which place patients at increased risk – have been recorded by NHS trusts and public health boards in England and Wales in the last two years, according to new research

The report, from Blackwater Law, medical negligence solicitors, shows over 40,000 serious incidents have been recorded by NHS trusts and health boards across England and Wales, between 1st April 2015 – 31st March 2017.

Although no standard definition of a serious incidents exists, they are considered to be adverse events whereby the consequences to patients and NHS organisations are so significant that a heightened level of response and investigation is justified.

Events that constitute a serious incident include unexpected or avoidable death, unexpected or avoidable injury resulting in serious harm, as well as incidents affecting an NHS trust’s ability to provide services.

How the data were collected

A Freedom of Information (FOI) request was sent to all 242 NHS trusts and Welsh health boards in England and Wales that existed during the period considered. The request asked for the number of serious incidents recorded by the individual NHS trust for both of the financial years 2015/2016 and 2016/2017 as well as a breakdown of incident type, where this could be provided.

Of the 235 NHS trusts and Welsh health boards in England and Wales whose data is included in the report, 132 provided a breakdown of the type of incidents. These amounted to 960 different categorisations and descriptions which were grouped into similar, commonly occurring incidents.

Five trusts (Kettering General Hospital NHS Foundation Trust, University Hospital Birmingham NHS Foundation Trust, The Dudley Group NHS Foundation Trust, United Lincolnshire NHS Trust and West Hertfordshire NHS Trust) provided data but explicitly refused permission for their organisation’s serious incident data to be used within this report and therefore have been omitted from the report in its entirety.

In addition, the report features no data relating to the two NHS trusts which did not respond to the original FOI request sent to them, or subsequent re-approaches (London North West University Healthcare NHS Trust and Norfolk & Norwich University Hospitals NHS Foundation Trust).

A significant figure

Data from the 235 NHS trusts and Welsh health boards included in the report records a total of 40,668 serious incidents between 1st April 2015 – 31st March 2017 (20,235 in 2015/16 and 20,433 in 2016/17)

Jason Brady, partner and medical negligence solicitor at Blackwater Law, commented:

“It is truly concerning to learn that the number of serious incidents being recorded by NHS trusts across England and Wales stands at such a significant figure. It is crucial to remember that these are not just statistics. Each of these incidents is a patient and a family that may be suffering, potentially unnecessarily, with possible long-term implications for their future and quality of life.”

The data was further broken down into three types of healthcare provider – acute and community health, mental health or ambulance trust

Grouping the data this way allowed the researchers to better understand the frequency and type of incidents being recorded by these different types of NHS organisation.

Acute and community trusts and health boards

Across the 171 acute and community health trusts and Welsh health boards a total of 27,789 serious incidents were recorded.

The five trusts and health boards recording the highest numbers of serious incidents during the period were:

• The Pennine Acute Hospitals NHS Trust (778)
• Betsi Cadwaladr University Health Board (668)
• Portsmouth Hospitals NHS Trust (389)
• Worcestershire Health and Care NHS Trust (338)
• Barts Health NHS Trust (290)

In contrast, those trusts and health boards recording the lowest numbers of serious incidents were:

• The Christie NHS Foundation Trust (1)
• Liverpool Heart and Chest Hospital NHS Foundation Trust (3)
• Public Health Wales (3)
• Cambridgeshire Community Services NHS Trust (5)
• The Clatterbridge Cancer Centre NHS Foundation Trust (6)
• Velindre NHS Trust (6)

The most commonly occurring serious incidents were the occurrence of pressure ulcers and damage, estimated to account for 22.4% of all of these incidents recorded. Accidents to service users and staff including slips, trips and falls (actual or suspected) accounted for 17.3%; delays and diagnostic incidents for 16.5% and clinical and patient care issues including sub-optimal care of the deteriorating patient, tests and test results for 15.9%, while an estimated 5.6% related to maternity, labour and delivery including neonatal.

Mental health trusts

Among the 53 mental health trusts in England which responded there were 11, 872 serious incidents recorded. Nearly half (47%) of the mental health trusts recorded over 100 incidents.

Of the findings in relation to mental health trusts Brady said:

“The data relating to mental health trusts is particularly concerning. To learn that approximately 24% of serious incidents recorded by these trusts related to unexplained death and approximately a further 23% to suicide and self-harm, including attempted and alleged, concerns not only us, but we expect also the public.”

Ambulance trusts

The researchers received responses from all 11 ambulance trusts across England and Wales which showed these trusts had recorded a total of 1,007 serious incidents in the two year period from 1st April 2015 – 31st March 2017. This figure increased 9.4% from 481 in the financial year 2015/2016 to 526 in 2016/2017. The increase in need for and use of ambulance services has been well documented, particularly over the recent winter months.

A disturbing snapshot

The report provides a snapshot of a concerning level of serious incidents at NHS trusts and public health boards in England and Wales, and recommends there should be greater transparency surrounding the number and nature of recorded serious incidents.

In a 2017 document, Learning from serious incidents in NHS acute hospitals, the UK’s Care Quality Commission notes that there are several problems with the way serious incidents are dealt with within the NHS and makes several recommendations for how to reduce the levels of these incidents in UK hospitals. These include

• Prioritising serious incidents that require full investigation and developing alternative methods for managing and learning from other types of incident.
• Routinely involving patients and families in investigations.
• Engaging and supporting the staff involved in the incident and investigation process.
• Using skilled analysis to move the focus of investigation from the acts or omissions of staff, to identifying the underlying causes of the incident.
• Using ‘human factors principles’ (i.e. understanding of interactions among humans and other elements of a system) to develop solutions that reduce the risk of the same incidents happening again.

Blackwater Law notes, however, that whilst the research shows an increase in serious Incidents being recorded, this data alone cannot suggest deteriorating care levels are being provided by a particular NHS trust.

It is also worth noting that this not by any means the first report to detail serious incidents in UK hospitals. Government data estimates that there are around 12,000 avoidable deaths in NHS hospitals each year. In the US it is estimated that around 210,000 people die each year from mistakes made in hospital.

• Blackwater Law is a team of specialist medical negligence and serious personal injury solicitors.
• Download the Report into Serious Incidents at NHS Trusts and Health Boards