Source · Select Committees · Public Accounts Committee
Recommendation 15
15
Rejected
Lack of centralised learning causes repeated patient safety incidents across trusts.
Recommendation
Written evidence submitted to us raised concerns about a lack of centralised learning leading to incidents being repeated across multiple trusts.31 When asked what it was doing to improve systemic learning from patient safety incidents, NHS England told us it had a “variety of mechanisms” but did not provide any detail on what these were.32
Government Response Summary
The government disagrees with establishing a national system for sharing data, stating that existing data sharing arrangements and patient safety data are already in place.
Government Response
Rejected
HM Government
Rejected
3. PAC conclusion: We are concerned there is far too little data on the factors behind clinical negligence, given its huge impact on people’s lives and NHS finances. 3a. PAC recommendation: The Department should establish a national system for sharing data between trusts and analysing trends. If there are barriers to sharing protected data, it should develop analysis on an anonymised basis to pull out lessons and provide early warning alerts to trusts. 3.1 The government disagrees with the Committee’s recommendation. 3.2 The government disagrees with this recommendation as there is already data sharing arrangements in place. 3.3 NHS Resolution’s (NHSR) Safety and Learning Team works with its members to interpret and triangulate claims data with other insights to inform local patient safety plans. It also publishes reports to highlight causes of harm to improve safety including from maternity claims. 3.4 The annual NHSR and NHS England GIRFT litigation data pack ensures that on the rare occasion where a claim has not been previously recorded as a patient safety event, organisations retrospectively review the case in line with their Patient Safety Incident Response Plan. This ensures that no patient safety incidents are missed and enables any further insights from the claim to be incorporated into improvement work. 3.5 As noted in the NAO Report (3.27), there is a consensus that claims data is very partial and does not provide a ‘live picture’ of the NHS. The insights derived from patient safety data are therefore more useful for the purposes of learning and responding to harm than litigation data. As described above in response to recommendation 2e and in The National Director of Patient Safety’s testimony to the Committee, there is an existing national system in place with around 3 million incidents reported per year. This data is used to derive and share learning, including through National Patient Safety alerts and national safety programmes.