PATI ENT SAFE T Y
First Do No Harm: key recommendations
It is clear that the voice of the patient needs to be louder and must be heard, to ensure lessons are learned, says Kate Woodhead RGN DMS. In this article, she continues the discussion around the Cumberlege Review, First Do No Harm, highlighting the key recommendations and calling for a long overdue overhaul of safety reporting systems.
The Cumberlege Review, First Do No Harm identified three particular sets of historical circumstances which caused disasters, pain and years of suffering for patients. These three areas were reported in some detail last month.1
This article will now focus on the overarching themes of the report, which are an equivocal set of recommendations, to try to unscramble the complexities of patient safety reporting and monitoring for patients and healthcare professionals. The Report2 investigated what had happened in the case of three seemingly avoidable disparate situations – the history of which go back to the 1950s: l Hormone pregnancy tests (HPTs) – tests, such as Primodos, which were withdrawn from the market in the late 1970s and which are thought to be associated with birth defects and miscarriages;
l Sodium valproate – an effective anti- epileptic drug which causes physical malformations, autism and developmental delay in many children when it is taken by their mothers during pregnancy;
l Pelvic mesh implants – used in the surgical repair of pelvic organ prolapse and to manage stress urinary incontinence. Its use has been linked to crippling, life- changing, complications; and to make recommendations for the future.
The Cumberlege team were horrified by the stories told by women (and most of the victims were women) of constantly being fobbed off by the healthcare system, who did not want to listen to their stories of pain and suffering. The review looks at not just what happened in the three individual cases but how the healthcare system reacted as a whole, and how that response can be made more robust, speedy and appropriate.3 The Report comments that they found the
OCTOBER 2020
healthcare system to be “disjointed, siloed, unresponsive and defensive” to the patients affected by these issues. The team identified that the systemic problems run very deep. Baroness Cumberlege also noted that: “The system is not good enough at spotting trends in practice and outcomes that give rise to safety concerns. Listening to patients is pivotal to that.” The team have made a series of overarching recommendations on how they suggest that patients can be more empowered to be heard, in future, and not have to wait years or decades for understanding of their complaint and reparation.
The recommendations
Each of the recommendations will be looked at to enable full coverage of all the issues. The nine recommendations are:
Recommendation 1: The Government should immediately issue a fulsome apology
on behalf of the healthcare system to the families affected by Primodos, sodium valproate and pelvic mesh. This has already taken place and was made in the House of Commons by Nadine Dorries, Minister for Mental Health, Suicide Prevention and Patient Safety, on the publication date. The Government has yet to provide a fuller response to the Report and, in some quarters, it is being spoken of as a “buried report”. It is to be hoped that the former Secretary of State for health and social care will use his authority to enable this report to be taken notice of and implemented. The Health Service Journal podcast has suggested that it is striking how few responses by professional bodies and Royal Colleges have been made public following publication of the report.4
Recommendation 2: The appointment of a Patient Safety Commissioner who would be an independent public leader with a
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