Progressing from rhetoric to results

It is incumbent upon anyone, including solicitors, who have an insight into the failings of the health service to attempt to assist in addressing the systemic failings and institutional shortcomings.

It is not a matter of solicitors “biting the hand that feeds them”. Things will always go wrong both because of human error and systemic failure.  There will always be cases that fall into the “grey area” requiring legal intervention, interpretation and support for those who have been harmed.  However, there is a need to reduce the grey area.  The priority has to be patients’ safety.  Solicitors take no pleasure in other people’s suffering and reducing the frequency of incidents caused by systemic failings has to be the aim.

We need to target avoidable mistakes or “never events”[10].  We need to reduce the number of incidents and therefore reduce litigation costs (not to mention additional costs of additional treatment within the hospital etc). 

There is clearly a failure on the part of the NHSLA to filter back into the Trusts the valuable information that arises from dealing with matters at the litigation/point of last resort stage. There is an opportunity to capture when there is a crash incident or an infection develops or there is an extended ITU stay or an adverse incident report is prepared.  There should be a consistent categorisation of incidents that allows a database to be built and analysed. The NHSLA should be assisting to build the “learning loop” hoped for at the time of preparing the Organisation with a Memory report[11]. An adverse incident that occurs should be capable of being tracked from occurrence through to the end of the litigation system (if it gets that far). Such a system would establish a central reference point and learning database.  How can lessons be learned/patients’ safety/costs saved improved when there is no “learning loop”?

There needs to be a cultural shift towards patients’ safety.  The NHSLA hold a huge amount of useful information such as expert reports, counsel’s advice etc which are all very costly to obtain in the litigation system.  Having obtained and paid for that information why are they not using this to feed back to patients’ safety initiatives?