Nine out of ten preventable deaths in the NHS are not reported
The Commons Health Select Committee heard evidence from experts in its first evidence session on its investigation into patient safety.
The NPSA runs a system where all NHS staff can report incidents or near misses so patterns can be spotted and the wider health community warned.
Incidents can include drugs administered in the wrong way or the wrong dose, medicines mixed up, the wrong operation carried out, a patient wrongly identified and broken or malfunctioning equipment.
Howard Stoate, a practising GP and Labour MP for Dartford, said the National Patient Safety Agency’s own estimates suggest there are 72,000 preventable deaths in the NHS each year.
However, the incident recording database had collected just 3,200 reports of patient deaths, in 2007/8. He said: “That is not just under-reporting, that is an extraordinary figure.
“If the public realised that only between five and ten per cent of preventable deaths are being reported they would have something to say about that.
“For example if only ten per cent of airline crashes were reported we’d have some concerns about that.”
NPSA chief executive Martin Fletcher replied that while there were ‘issues’ around under reporting, reporting rates were continually improving.
Sir Bruce Keogh, medical director of the NHS, said no-one was ‘comfortable’ with under reporting but he said people could not be ‘forced’ to report incidents.
He said it was the staff member’s personal, moral and professional duty to report incidents.
In 2004 the NPSA produced a report that said one in ten patients admitted to hospitals will suffer a patient safety incident – almost one million people in 2002/3 – and up to half of these could have been prevented. It added that 72,000 of these incidents may have contributed to the death of the patient.
Dr Richard Taylor, Independent MP for Wyre Forest, said the Committee was ‘absolutely appalled’ that one in ten patients will suffer an incident and said this was the reason they were conducting an investigation. It was ‘utterly unacceptable’, he said, and asked about the financial cost to the NHS of patient safety incidents.
Sir Bruce said that litigation costs were around £600m a year while Christine Beasley, chief nursing officer, said hospital associated infections such as MRSA cost the health service around £1bn a year because of the extra days infected patients have to stay in hospital.
Mr Taylor added that there were 25,000 deaths annually from blood clots after stays in hospital which can be prevented with drugs and this cost the health service around £640m.
He said: “The costs are astronomical and here we are trying to find enough money for Nice (the National Institute for Curbing Expenditure) to afford certain treatments.”
Evidence submitted by the Department of Health to the Committee showed there were 796,106 incidents reported to the NPSA in 2007/8 and the majority resulted in no harm to patients. However there were 48,951 incidents where the patient suffered moderate harm, 7,101 severe harm and 3,282 deaths.
The Government’s chief medical officer Sir Liam Donaldson has called for the NHS to learn from industries such as aviation where safety and reporting incidents or near-misses is embedded in the culture.
A list of ‘never-events’ is being drawn up by experts including operating on the wrong patient, or carrying out the wrong operation, which hospital trusts will not be paid for.