Saturday, August 14, 2010

Take NOTE Sandwell Mental Health Trust - Patient Safety Alert UK


Sourced To The National Association For LINks Members (NALM)

Local Involvement Members who monitor Health and Social Care services in the UK have banded together in some parts of the the UK to form NALM . UserWatch has been sent a bulletin sourced to them which is self explanatory :


Dear Members, if a Trust that you monitor is on this list below we advise you to contact the Chief Executive urgently to ask what action they are taking to implement the SAFETY ALERTS issued by the National Patients Safety Agency. These alerts are meant to prevent deaths and serious harm to patients. We also recommend contacting your CQC regional manager to ask what action they are taking to ensure compliance with this critical safety tool. All of the Trust shown below have been asked by the DH to comply with the saftey alerts, yet some have increased the number not attended to. These are marked in green. The full report is attached.

All the best. Malcolm Alexander, Chair, NALM






Action against Medical Accidents (AvMA – the charity for patient safety and justice) has today published the findings of its latest research into whether NHS trusts are implementing potentially life-saving patient safety alerts issued by the National Patient Safety Agency (NPSA). The results make disturbing reading.

In spite of the public concern following AvMA’s first report in February 2010, which prompted the Department of Health to issue a reminder letter to all trusts NALM is collaborating with AvMA to ensure that all hospital and PCT comply with patient safety alerts :

"NALM is appalled that 25 hospitals in England have failed to take action in response to 10 or more Safety Alerts issued by the National Patients Safety Agency (NPSA).

We are alarmed that 4 Primary Care Trusts (PCTs), the bodies that pay for local health services and are supposed to ensure the highest standards of care, have between them failed to respond to 57 Safety Alerts.

Safety Alerts are issued by the NPSA to reduce the risk of harm to patients. In some cases failure to deal with a Safety Alert can lead to the death of a patient, incapacity or life long suffering.

NALM has also asked for assurances from the Department of Health and the NHS Litigation Authority action will be taken in every case where an NHS Trust has ignored a Safety Alert. We will also take steps to ensure that evidence of failure to comply is published in every part of the county." ·

As of 7th June 2010; there were 1,242 incidences of individual patient safety alerts, for which the deadline had passed, not having been complied with; 63% of trusts had failed to comply with at least one alert.

Only 37% declared that they had ‘completed’ all required actions in all alerts or that there was ‘no action required’; 29 trusts had not complied with 10 or more alerts. 11 of these are ‘Foundation’ trusts.

Even the extra-urgent “Rapid Response Alert’ on ‘Oxygen Safety in Hospitals’ (deadline for completion: 29th March 2010) had not been complied with by 116 trusts.

‘Safer Use of Injectable Medicines’ (Deadline 31st March 2008) had still not been complied with by 67 trusts. Both alerts, like the vast majority of them, had been sparked by a number of avoidable deaths and serious injuries.

As of 16th June, the national regulator, the Care Quality Commission (CQC), had not contacted a single trust identified by our report of February 2010 – even those with multiple alerts outstanding, or alerts which were years past the deadline, to demand compliance or ask them to explain themselves.
There remains no central policy or guidance on who should be monitoring compliance with patient safety alerts, or who should intervene with trusts who are not complying; AvMA Chief Executive, Peter Walsh, said:

“These figures are staggering bearing in mind that we are dealing with recognised life and death issues, and the Department of Health itself issued a wake-up call to trusts following our last report. There can be no excuse for trusts continuing to put lives at unnecessary risk by not complying with these alerts. We commend the 146 trusts who have shown that the requirement to implement alerts by the deadline can be met for their commitment to patient safety. We are also grateful that at long last the CQC is taking some action, but we remain deeply concerned. Urgent action needs to be taken now over non compliant trusts. We also need to know how, following the cuts announced recently including abolition of the NPSA, the system can be made robust in the future”.

AvMA are seeking an urgent meeting with Ministers and the bodies responsible for quality and safety in the NHS to discuss the report and AvMA’s recommendations for addressing the problems it identified.

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