NHS heading for major new scandal causing ‘severe harm and death’, safety commissioner warns

The NHS is heading for another major health scandal unless care urgently improves, the government’s first patient safety commissioner has warned.

Healthcare chiefs are focusing too much on “financial control” and “productivity” rather than the genuine concerns of those in their care, says Dr Henrietta Hughes. If things don’t change, it will only be a matter of time before the health service faces another disaster in healthcare, she adds.

The warning comes as the NHS struggles to cope amid widespread strike action by nurses, paramedics and 999 call handlers.

In recent weeks, pressures on waiting times at A&E have seen patients waiting for days to be seen by specialists and in some instances dying before ambulances arrive.

The Independent has revealed a catalogue of failings in maternity care in Shrewsbury, East Kent and Nottingham, as well as buckling systems in mental health.

In her first report since being appointed last year, Dr Hughes drew a direct comparison to the failings in care in Staffordshire in the 2000s when 1,200 people died due to poor patient care. It is considered one of the largest-ever healthcare scandals in the UK and emblematic of negligence in the NHS.

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“Unless leaders set a strategic intention to listen to patients and act, we are heading straight back to the days of Mid Staffs and other health scandals, severe harm, and death,” she said.

“My clear message to leaders is – don’t let this happen on your watch.”

Dr Hughes was appointed to respond to the 2020 Cumberlegede review which highlighted three areas of clinical concern – drugs used in epilepsy, pelvic mesh surgery and hormone pregnancy tests.

She was previously the NHS’ national freedom to speak up guardian in charge of overseeing national whistleblowing services.

Tens of thousands of women were harmed by the insertion of pelvic mesh supposed to help with urinary incontinence while thousands of children were exposed to sodium valproate, a treatment for epilepsy.

In her report, Dr Hughes said patients had described long waits to access specialist pelvic mesh centres, suffering in pain and facing a “lack of respect” from health services.

It is estimated that 100,000 people, mostly women, have had pelvic mesh surgery in the past two decades, and around 10 per cent of those have developed long-term severe health problems following the procedure.

Following the Cumberledge review, specialist centres for patients harmed by mesh procedures were set up by the NHS.

However, the patient safety commissioner said she “lacked confidence” that these centres were developed with the involvement of patients after long delays and difficulties accessing the services were reported.

Despite revelations in the Cumberledge review of the drug sodium valproate causing deformities in children when taken by women during pregnancy, Dr Hughes said three babies a month were still being born following exposure to the drug.

She said concerns over patient harm which led to the review continue today and that needed to change.

“I have discovered that we need a seismic shift in the way that patients’ and families’ voices are heard,” she said. “This requires changes in legislation, regulation, policy, commissioning, education, professionalism, attitudes, behaviours, and culture. In essence, everything we do as a healthcare system because everything we do is about patients.

“I want national bodies, regulators, professional bodies, frontline staff, and patient groups to step forward and demonstrate their commitment to patient safety. I recognise that there are severe pressures on the health service, but as long as safety is at the heart of everything, we will reduce avoidable harm to patients.”

Dr Hughes also called on health leaders to add patients to their boards, adding: “Without listening and acting on patient voices, safety continues to be compromised and patients and families continue to suffer the consequences of harm.”

A Department of Health and Social Care spokesperson said: “Patients are at the heart of what we do and we appointed the first ever patient safety commissioner to further listen to and champion patients’ voices.

“More widely, we’re improving the safety of care by driving transparency and requiring trusts to inform patients if their safety has been compromised, putting in place legal protections for whistleblowers, and by implementing the first NHS Patient Safety Strategy to create a safe learning culture across the NHS.

“This year we will also establish a new independent body, the Health Services Safety Investigations Body, to investigate serious patient safety incidents in England. We will continue to work closely with Dr Hughes so we can better deliver safe, patient-centred care.”