Independent body must investigate NHS failures (Image: Getty)
An independent body is urgently needed to prevent NHS hospital trusts from investigating their own failures, say harmed patients and bereaved families campaigning for justice.
Paul Whiting, Chief Executive of the UK patient safety charity, Action against Medical Accidents – AVMA – and James Titcombe, Chief Executive of Patient Safety Watch have backed the calls, stating that that the current system is preventing lessons from being learnt.
The calls were prompted by the case of nine-year-old Dylan Cope, who died in December 2022 after being discharged from hospital despite showing ‘red flag’ symptoms. A coroner subsequently ruled Dylan’s death “would have been avoided if he had not been erroneously discharged.”
His devastated parents have spent over two years fighting for answers, yet the hospital still cannot identify the doctor who sent him home.
Now the trust has launched a third investigation in an attempt to identify the mystery medic, but Dylan’s parents say such a probe should be carried out by people not linked to the trust where their son was failed because the hospital should not be ‘marking its own homework.’
Dylan, from Newport, Wales, visited the Children’s Emergency Assessment Unit at Grange University Hospital on December 6, 2022, with a GP note explicitly stating “check for appendicitis.” But this critical note was never read. Instead he was discharged the following day with a generic flu leaflet, despite his worsening condition and abdominal pain.
Days later, his father Laurence desperately called the hospital for advice, only to be redirected to NHS 111, where numerous errors delayed Dylan’s attendance to hospital, reducing his chances of survival. When Dylan was finally readmitted on December 10, he was treated for sepsis caused by a perforated appendix but died four days later. His parents learned his sepsis treatment on readmission had been poor, likely causing cardiac arrests following anaesthetic and further reducing his chances of survival.
Last May Gwent coroner Ms Saunders concluded that had Dylan not been erroneously discharged on 7 December, the surgical team would have identified his condition and treated him in time.
She described what happened as “a gross failure of basic care” and criticised Aneurin Bevan health board for an “organisational system failure.” The health board has since apologised, admitting that Dylan’s death was entirely preventable.
“The only person who got it right was the GP,” said Dylan’s mother, Corinne. “After that, everyone let him down.”
She added: “Almost every system to examine this has been ineffectual in some way and we are still in this unfortunate position of not only having to repeatedly battle for things over 2 years on and are not afforded the full picture as to what happened. Without this we cannot be sure the same mistakes will not happen again. These issues are not isolated to Dylan’s case; thousands have reported similar frustrations and issues including blatant lies and cover ups.”
Paul Whiteing, Chief Executive of AVMA said: “Unless investigations are carried out by qualified people who have no axe to grind and are not linked to the hospital there is a risk any investigation is not robust, good quality or at worst could be vested in a certain outcome. We get many families and patients who say they feel they do not trust the hospital investigations because of this.”
Mr Whiteing added: “We are calling for families or patients to be involved in the process of the investigations – family members observe and see things and therefore should be part of any report. All too often they are not.”
Improve patient safety to save lives (Image: Getty)
James Titcombe, the chief executive of Patient Safety Watch, who did not get a full explanation for 17 months after his son Joshua died of sepsis in 2008 at nine days old, said he shares these concerns.
He said research had found that if the UK matched the best performing countries for patient safety, thousands of lives could be saved each year.
He said: “When things go wrong in the NHS, sadly, too often the culture remains one driven by fear and protecting the reputation of the organisation and although there is work ongoing to change this, there is still a long way to go.
People affected by healthcare harm need to be given honest explanations, meaningful apologies and care and support to help them heal and recover as well as might be possible. Instead, too often patients and families frequently experience ‘compounded harm’, where the response and investigation process are managed so poorly that further harm is caused as a consequence.
He added: “Even when there has been an independent investigation, recommendations made are often not fully implemented. There needs to be a better system of oversight to ensure that recommendations from patient safety investigations are prioritised and actually result in the change intended.”
NHS must be transparent when things go wrong (Image: Getty)
A Welsh Government spokesperson said:
“NHS Wales works hard to ensure the best possible care is available for everyone, but we know thatsometimes things can and do go wrong.
“We are considering the recommendations of our Ministerial Advisory Group which was set up to reflect on governance in NHS Wales and provide advice to strengthen accountability.
“We have also listened to the public to improve care via our “Putting Things Right” consultation. We are working with NHS Wales to make changes following this feedback, to simplify the complaints process, and ensure people are engaged with compassionately and in a timely way.”