NHS Resolution publishes 3 reports following thematic review of claims relating to care provided in Emergency Departments in England

The reports focus on three key areas: (i) high-value and fatality-related claims, (ii) missed fractures, and (iii) hospital-acquired pressure ulcers and falls.  In this article we look at some of the key points arising out of each of the reports.

High-Value and Fatality-Related Claims Report

For this report NHS Resolution conducted a thematic review of 16 claims that were valued at more than £1 million and also 86 claims involving patient deaths.  The review identified five common and emergent themes:

• Diagnostic error including missed signs of deterioration.
• Failure to investigate and diagnose, and missed, wrong and delayed diagnoses.
• Failure to recognise the significance of repeat attendance or patient not re-attending when advised.
• Delays in care, including specialty reviews and missed therapeutic options.
• Problems with communication and escalation and cross specialty team working.

The report makes a range of recommendations to seek to address these themes, for example:

• National Early Warning Scoring should be used consistently to identify deteriorating patients and take effective action.
• The Consultant Sign Off standard that was introduced by the Royal College of Emergency Medicine in 2010 should be implemented, in order to ensure, amongst other things, that patients who re-attend ED with the same condition within 72 hours of discharge should be seen by a consultant.
• There should be regular MDT meetings between senior ED clinicians and radiology/diagnostics teams.
• The CQC’s “Patient FIRST” principles and professional standards (published in 2018) should be implemented, which should involve agreed robust induction and supervision programmes, routine use of SBAR processes and early warning resources, agreed escalation processes, and unit level, multi-professional training.

Missed Fractures Report

According to this report, 5.1% of all ED attendances in 2018/19 were because of a dislocation, fracture, joint injury or amputation.  In a very small proportion of these attendances a fracture that could have been identified and treated was missed, with consequent harm to the patient.  For this report NHS Resolution reviewed 78 cases of this nature that arose in previous years (2015/15 and 2017/18) and some of its key findings can be summarised as follows:

• In most cases (64%) an appropriate x-ray examination was completed, but the error occurred later in the care pathway, i.e. at interpretation or follow-up action stage.
• Where an x-ray examination was not performed it was almost always due to the clinician erroneously diagnosing a soft tissue injury on the basis of their examination of the patient.
• Where an x-ray was appropriately performed the main point of error was the interpretation by the ED clinician of the image (i.e. the image was not reviewed by a radiologist or radiographer).
• The most common missed fracture was fracture of the hip. The report notes that this is an issue that particularly affects older people who have fallen, with 80.6 as the mean age of the Claimants in this cohort of cases reviewed.

In terms of recommendations, the report notes that there are already existing standards and guidelines which, if they had been fully implemented and followed, would have prevented fractures from being missed in most cases.  However, it acknowledges that there were wider factors that influence what happens in EDs, including “demand, capacity and outflow”.  Nonetheless, the report makes several important recommendations, which are separated into five themes, i.e. (i) workforce, (ii) models of care, (iii) ED multidisciplinary meetings, (iv) training and competence, (v) hip fractures.  The recommendations include the following:

• Providers should develop advanced practitioner and assistant practitioner radiography job roles over the next five years, to make the best use of the workforce in fracture management pathways.
• Providers should work in partnership within their Integrated Care System to determine how Same Day Emergency Care hubs can be provided at least 12 hours a day, 7 days per week.
• CT scanning capacity should be increased over the next five years, which will particularly help with diagnosing scaphoid and hip fractures.
• There should be a national training qualification for interpretation of emergency x-rays.
• Hip fracture patients should be prioritised in terms of ensuring that staff working in ED have the expertise and resources to make accurate diagnoses.
• As in the report relating to high-value and fatality-related claims, emergency medicine/radiology MDT meetings, similar to those established within cancer care, are encouraged.

Hospital Acquired Pressure Ulcers and Falls Report

Pressure Ulcers

NHS Resolution reviewed 15 patients who had more than one pressure ulcer site.  It is recognised this is only a small number of claims, however, the findings can be summarised as follows:

• The pressure sores were to the sacrum (9), buttocks (6) and other (8 – including heels, shoulder, scrotum, calf and malleolus).
• There was no significant difference in attendance between day and night shifts.
• There were failures to undertake appropriate and accurate risk assessments, with patients being asked about pressure sores rather than inspecting pressure sore areas, which would be good practice.
• The Waterlow assessment tool (used to assess a patient’s risks of pressure sores) has its challenges and it has not been updated since 2005. Some of the terminology is subjective and potentially confusing and can result in incomplete or inaccurate risk assessments.
• There was disparity in the level of information within the 4 Serious Investigations undertaken with only one report having a robust action plan that would mitigate future risk.

Falls

NHS Resolution analysed a total of 220 ED claims, of which 35 involved patients falling. The review found:

• The falls analysed involved the following:
• There were more falls during Autumn and Winter than Spring and Summer though there is no rationale for this trend. Whilst more patients attended ED during a day shift, more falls occurred in the early evening or night.

1. Failure to use/inappropriately using bed rails;
2. Lack of 1:1 supervision;
3. Lack of nutrition/hydration;
4. Toileting alone;
5. Use of a low rise trolley;

• The most common type of injury was a fractured bone with other types of injury including lacerations, soft tissue damage and intracranial haemorrhage. One patient died as a result of a fall in ED.
• Most patients did not have a risk assessment completed despite the average time in ED being over 7 hours.
• There is no universal or nationally recognised risk assessment tool for falls which presents potential for variation in standards.
• There was a lack of proactive nursing interventions and an absence of close observation of high risk patients.
• Communication between clinical areas was a significant factor in falls cases. Nurses taking over care did not receive adequate information to implement the appropriate level of care.
• There was inconsistent local incident reporting and the level of information provided in the reports which were completed.

The report identifies four themes and provides the following recommendations:

• Risk assessments: there should be a national approach to these to avoid variations between Trusts. An electronic screening page should be designed to inform all risk assessments to ease the burden of duplicating information.
• Standardised tool for handover: this would ensure that relevant information is consistently shared and would reduce the risk of error.
• Proactive nursing care:

1. ED nurse staffing must be organised so that there is dedicated nursing time available to deliver regular and frequent high quality nursing care to all patients.
2. There should be processes in place for providing 1:1 supervision and where this is not available, the use of observable trolleys.
3. ED departments should have their own pressure relieving aids or be able to acquire them from other departments.

Reporting and investigating incidents:

• Some mandatory information should be included within incident reports, such as staffing, skill mix and activity to provide context and highlight shortfalls.
• The reports should have executive sign off.
• Organisations should provide appropriate risk management and SI investigation training to all levels of staff.

Conclusion

By analysing clinical negligence claims NHS Resolution has been able to draw on an important source of knowledge in order to prepare these reports, which contain valuable insights and recommendations that should, when implemented, make a significant contribution to improving patient safety in Emergency Departments.  Claims involving care provided in Emergency Departments cost the NHS more than £300 million in damages and legal costs in 2020/21, with significant impacts on patients, their families, and medical professionals involved in their care.  These reports highlight that, although Emergency Departments are currently operating under a great deal of pressure, there are certain practical steps that Trusts can take to avoid incidents such as missed fractures, pressure ulcers and falls in particular.  These should help to drive down the NHS’s expenditure on claims, and will no doubt lead to better experiences for patients and staff alike.

A link to the reports can be found here.

Please contact Sean Doherty, Heather Durston-Hillyer, Ciaran Claffey or Charlotte Kistell-Gough if you wish to discuss these reports further.