NHS Resolution Research Articles

Risks to patient safety in remote consulting.

Remote consulting was rolled out across general practice in 2020 in response to the COVID-19 pandemic. Although most consultations are carried out safely, in some cases remote care has contributed to adverse outcomes. To understand where the risks lie in delivering primary care remotely. Mixed method study in UK primary care settings including general practice, out of hours and 111 services. Data was collated from NHS England complaints quarterly reviews, NHS Resolution cases, 111 Wales, the HSIB report into 111 COVID services and longitudinal case ethnographic cases studies of 11 general practices. 2 reviewers coded the data and identified themes. There are staff, patient, and setting factors that contribute to risk in remote consulting. Staff factors include communication skills, over-reliance on a previous diagnosis made remotely, failure to recognise clinical findings or the urgency of a case, over/under prescribing/investigating and referring and safety netting. Patient factors include impaired communication, repeated telephone consultations, unstable chronic disease, and certain medical conditions such as chest and abdominal pain. Risk was encountered when settings had limited telephone lines, call handlers or clinicians, or where access to appointments was either restricted, hard to navigate, or where inappropriate layers of triage were applied. Processes had not always adapted for remote working, leading to risk in delayed access to acute prescriptions and delayed referrals. Attention to staff, patient, and setting factors can allow risk to be identified and addressed when providing care remotely. .

NHS Resolution to rule on Glastonbury pharmacy opening following objection

NHS Resolution to rule on Glastonbury pharmacy opening following objection

342 The NHS in crisis; assessment of the impact of litigation trends over 20 years in general surgery

Abstract Introduction A rising proportion of the NHS annual budget is being spent on medico-legal costs, with over 1.6% of total UK healthcare spending on litigation in the year 2018/19. This is a risk to both patient care and public opinion of the NHS. Despite this, surgical litigation is a relatively understudied subject. This paper aims to assess the scale of the litigation crisis to fuel further work into mitigating it and improve value for patients and staff alike. Method Data was obtained via a Freedom of Information request from NHS resolution for all claims relating to General Surgery between January 2000 and December 2020. Results 17,542 claims were made against General Surgical units in England with a gradual increase in claims per year. The successfully closed claims cost £1.3 billion. This was out of proportion to both inflation and case volume. The three most common causes for claims were intra-operative problems, failure/delay of treatment and failure/delay of diagnosis. Conclusion The NHS is threatened by a litigation crisis, with case volume and cost rising out of proportion to surgical workload and inflation. The most common causes for claims against surgical units are known complications discussed as part of a standard consenting process, indicating that current practice may fail to achieve adequate patient understanding of surgical risk. More research is required to design methods to improve the current consenting process, and to identify specific demographics that may increase an individual’s propensity to make a claim and establish modifiable risk factors.

Exploring Patient Safety in Maternity and Midwifery Care

This is the first of a series of four co-written papers for the Advancing Practice series. In this paper we briefly explore the relevance of patient safety within the context of NHS Resolution’s publication The second report: The evolution of the Early Notification Scheme.1 In this series, we hope to support Midwives’ understanding of the current maternity safety landscape.

Litigation in Septorhinoplasty Surgery: A Pan-Specialty Review of National Health Service (the United Kingdom) Data.

Success in septorhinoplasty surgery can be difficult to assess due to a lack of objective and measurable outcomes. If patients' expectations are not met, it places surgeons performing septorhinoplasty at risk of litigation which can be stressful and costly. The National Institute of health (NHS) Resolution is a government-funded organization in the United Kingdom that provides expertise to the NHS on resolving patient concerns. Data were requested from NHS Resolution for claims involving septorhinoplasty surgery over a period of 5 years between April 2015 and April 2020. Rhinoplasty claims performed by all specialties were included. Data included the claim status, incident details, alleged injury, damages claimed, and damages paid. A total of 31 claims were identified by the study, equating to a total cost of £1,347,336.10. Of the 31 claims for rhinoplasty or septorhinoplasty, 9 cases were open (29%, £962,361.00) and 22 cases were closed (71%, £384,975.10). The common causes for claims were "intraoperative problems (32%)," "failure to warn-informed consent (19%)," and "foreign body left in situ (13%)." The most common injuries were "cosmetic disfigurement (39%)," "unnecessary pain (29%)," and "additional/ unnecessary operation (29%)." This study highlights the need for improved awareness of clinical negligence claims among surgeons who perform septorhinoplasty. Results are applicable to all specialties who perform the procedure. The study highlights the importance of assessing patients' motives and expectations prior to surgery and emphasizes the need for a well-documented rigorous consent process.

The costs of avoidable injury from childhood cancer: Litigate or mediate?

We write as experienced paediatric practitioners who have been involved in medico-legal proceedings where cases related to childhood cancer practice have featured frequently. We will use the service evaluation of Professor David A Walker's last 35 cases, where all but seven concerned children with tumours of the brain or spine to illustrate the concerns that families raise. We refer to the evidence from the HeadSmart programme (www.headsmart.org.uk), which seeks to accelerate diagnosis by raising awareness of the disease and symptoms. We use the experience of Dr Jonathan AG Punt to illustrate the legal issues that apply and explain the way that significant quantum calculations are applied to cases of this type. The current move by NHS Resolution to explore the expanded role of mediation will be discussed and the need for research to explore the precise way that mediation could be developed to offer an alternative approach to conflict resolution.

End-of-term reports on clinical negligence claims.

John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses the annual reports of NHS Resolution and the Medical Defence Union.

Obstetrics and gynaecology and the law.

Litigation over medical mishaps – NHS Resolution – extent of damages and costs – the relationship between doctor and midwife – celebrated or notorious cases, Mid Staffs, Morecambe Bay, Northwick Park – informing patient of risks – meaning of wrongful birth – contemporary tests for negligence.

Litigation related to anaesthesia: analysis of claims against the NHS in England 2008-2018 and comparison against previous claim patterns.

We reviewed all 1230 claims against anaesthesia notified to NHS Resolution (formerly the NHS Litigation Authority, 1995-2017) in England between 2008 and 2018. Claims were categorised by incident type, severity (whether physical or psychological), and cost, and comparisons were made against a similar published analysis of data from 1995 to 2007. While the annual number of claims against anaesthesia increased by 62% from the earlier period, anaesthesia now accounts for smaller proportions of all claims submitted to NHS Resolution (1.5% vs. 2.5%) and of the total cost of all claims (0.7% vs. 2.4%). The absolute costs related to anaesthesia claims rose over 300%, totalling £145 million between 2008 and 2018, but the mean cost per closed claim (retail price index adjusted) fell by 6% to £74,883. The most common clinical categories were regional anaesthesia (24%), inadequate anaesthesia (20%) and drug administration (20%). Claims related to airway management, central venous catheterisation and cardiac arrest remained infrequent but severe and costly. The proportion of claims relating to regional anaesthesia and obstetric anaesthesia fell significantly, but claims relating to peripheral nerve blockade doubled. Our analysis includes categories relating to organisational and human factors which are present in a substantial proportion of claims; categories with the highest mean cost per claim included delayed care, planning, monitoring and consent. Overall, the specialty of anaesthesia is at low risk of litigation. Our analysis provides important insights into current and changing patterns in claim distributions that may help improve the quality of patient care and reduce future litigation. We recommend the establishment of a structure for national review and learning from all cases of litigation.

Trends in emergency department litigation within the NHS: a retrospective database analysis

The objectives of this study are to examine trends in litigation related to emergency department care within the NHS. The study is based on retrospective database analysis. NHS Resolution databases of litigation activity pertaining to Type I emergency departments within the NHS are used. The main outcome measures were number of claims, number of successful claims, costs associated with litigation and costs per claim, all in comparison to patterns of ED attendance numbers and inflation. The results showed that the annual cost of litigation relating to emergency department care within the NHS has increased from £25.5 million in 2005/6 to £161.9 million in 2017/18. Mean cost per claim has increased from £58,252 in 2005/6 to £168,966 in 2017/18. The number of claims received has increased significantly; the proportion of these which were successful has remained constant. Therefore, it was concluded that the costs of litigation are increasing disproportionately to inflation and attendance numbers. Multiple potential causes are discussed, with significant implications for clinical practice.

The use of inter-professional education (IPE) healthcare law and ethics scenario based learning sessions amongst nursing, midwifery and law students: A qualitative investigation

BackgroundThe Nursing and Midwifery Council (NMC, 2018) require registrants to practice ethically and lawfully. Nevertheless, in 2019–2020, the NMC received 5704 referrals regarding registrants' fitness to practice, many of these referrals related to registrants' criminality, clinical competence, and misconduct. Additionally, litigation within healthcare remains a concern. NHS Resolution (2020) reported costs of payments relating to clinical negligence schemes of £2324.2 million in 2019/20. This paper discusses a qualitative investigation of healthcare law and ethics teaching and learning within undergraduate midwifery and nursing curricula and the use of scenario based (inter-professional education) IPE sessions amongst nursing, midwifery and law students. MethodsTwo scenario based IPE sessions attended by nursing, midwifery and law students were delivered in addition to existing curricula. Scenarios were based on real life cases. Students collaborated to identify means of managing legal and ethical issues arising from the scenarios. Sessions were facilitated by lecturers from the schools of law, midwifery and nursing. Semi structured interviews were completed with IPE session participants and academics with an interest in healthcare law and ethics (students n = 3, academic staff n = 3). Thematic content analysis was applied to interview data.FindingsScenario based IPE sessions are valued by participants who claim they are effective in enabling the development of knowledge and understanding of healthcare law and ethics while providing insight into the application of theory in practice. Participants claimed that healthcare law and ethics was a fundamental part of caring professions and essential to nursing and midwifery curricula. ConclusionSubstantial numbers of nurses and midwives are called to account by their professional body and in law for issues related to their practice, with significant financial and personal costs. Healthcare law and ethics remains fundamental to professional practice with IPE scenario based sessions offering a means to develop knowledge and enable students to consider ethical, legal and professional issues.

Considering claims against the NHS.

John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses the NHS Resolution annual report and accounts for 2020/21 and recent advice from the Medical Defence Union.

Giving essential content to the National Patient Safety Syllabus and curricula.

John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses several publications from NHS Resolution that should provide essential educational content for enhanced training on patient safety.

Litigations in trauma and orthopaedic surgery: analysis and outcomes of medicolegal claims during the last 10 years in the United Kingdom National Health Service.

This study analyses the outcomes of litigation claims in trauma and orthopaedic surgery between 2008/2009 and 2018/2019.Utilizing a formal request to the NHS Resolution under the Freedom of Information Act, the data related to claims against orthopaedic surgery were obtained. A total of 8548 claims were analysed and re-grouped to perform a meaningful analysis for the type of claims and the type of injuries.The total pay-out cost for the settled claims was over £1.2 billion. The most common types of claims were related to mismanagement (39.0%), diagnostic issues (17.6%), perioperative issues (15.9%) and alleged incompetence (10.2%). The most common primary causes for claims were patients’ dissatisfaction (52.2%), damage to the limbs (19.0%) and neurological injuries (9.2%).The highest amounts of damages paid out were related to patients’ dissatisfaction (37.7%), burns and bruising (31.0%), neurological injuries (24.5%) and damage to the limbs (22.3%). The number of claims and the pay-out cost were found to be steadily increasing; however, there was a slightly declining trend observed during the last two years.The cost of litigation continues to have a significant financial impact on the NHS. The recent declining trend is encouraging; however, surgeons need to take consistent diligent steps to avoid preventable causes that lead to litigation claims.The proposed change in the coding system of claims in the NHS Resolution will not only help to formulate a clear classification system but will also improve the learning from previous experience.Cite this article: EFORT Open Rev 2021;6:152-159. DOI: 10.1302/2058-5241.6.200100

The financial and human costs of obstetric clinical negligence claims in the NHS

NHS Resolution's Director of Safety and Learning Denise Chaffer discusses the strategies used to address the incidence of clinical negligence claims in obstetrics and the high costs that such incidents can have for the NHS.

RPS urges government not to end state-backed indemnity for pharmacists delivering COVID-19 vaccinations

The Royal Pharmaceutical Society (RPS) in England has said it is “surprised and concerned” to learn that community pharmacists providing booster COVID-19 vaccinations will, from 31 August 2021, be asked to cover the cost of indemnity insurance themselves. NHS Resolution, which was the NHS Litigation Authority, had previously said that pharmacies delivering COVID-19 vaccinations operating […]

The cost of consent: why healthcare providers must be compliant with the Montgomery principles.

The cost of clinical negligence in the UK has continued to rise despite no increase in claims numbers from 2016 to 2019. In the US, medical malpractice claim rates have fallen each year since 2001 and the payout rate has stabilized. In Germany, malpractice claim rates for spinal surgery fell yearly from 2012 to 2017, despite the number of spinal operations increasing. In Australia, public healthcare claim rates were largely static from 2008 to 2013, but private claims rose marginally. The cost of claims rose during the period. UK and Australian trends are therefore out of alignment with other international comparisons. Many of the claims in orthopaedics occur as a result of "failure to warn", i.e. lack of adequately documented and appropriate consent. The UK and USA have similar rates (26% and 24% respectively), but in Germany the rate is 14% and in Australia only 2%. This paper considers the drivers for the increased cost of clinical negligence claims in the UK compared to the USA, Germany and Australia, from a spinal and orthopaedic point of view, with a focus on "failure to warn" and lack of compliance with the principles established in February 2015 in the Supreme Court in the case of Montgomery v Lanarkshire Health Board. The article provides a description of the prevailing medicolegal situation in the UK and also calculates, from publicly available data, the cost to the public purse of the failure to comply with the principles established. It shows that compliance with the Montgomery principles would have an immediate and lasting positive impact on the sums paid by NHS Resolution to settle negligence cases in a way that has already been established in the USA. Cite this article: Bone Joint J 2020;102-B(5):550-555.

The effect of the Montgomery judgment on settled claims against the National Health Service due to failure to inform before giving consent to treatment.

A landmark legal judgment in March 2015 (Montgomery) changed the test for determining negligence due to failing to inform patients before consent, by moving away from asking what a reasonable doctor should disclose and asking instead what a reasonable patient would expect to know. We sought to determine the effect Montgomery has had on settled claims due to failure to inform compared with claims for other reasons and whether legal firms are adding contributory claims of failure to inform to other principal allegations of negligence. A Freedom of Information request to NHS Resolution provided data on the number of settled claims against the NHS (2005-19) for any cause and where failure to inform before consent was the principal or contributory cause. Time-series regression was used to compare trends before and after 31 March 2015. The trend in claims/year increased 4-fold for failure to inform (an increase of 9.8/year before 2015 vs. 39.5/year after 2015, P < 0.01), 2.7-fold when failure to inform was the principal cause (7.9/year vs. 21.2/year, P = 0.02) and 9.9-fold as a contributory cause (1.9/year vs. 18.3/year, P < 0.01). There was no material difference in claims due to other causes (334/year vs. 318/year, P = 0.84). Montgomery has led to a substantial increase in settled claims of failure to inform before consent, with no coincident change in claims for other causes. The increase in contributory compared with principal causes suggests that lawyers are using the judgment to increase the chances of a successful claim against the NHS.

Creating a just and learning culture through staff support

A just and learning culture consists of a balance of fairness, justice, learning and taking responsibility for actions. It is not about seeking to blame an individual when care falls short of expectations or goes wrong. A recently published report from NHS Resolution, Being fair, sets out the argument for organisations to adopt a more reflective approach to learning from incidents and supporting staff. Instead of asking ‘who is to blame?’ or ‘what did you do?’, try asking ‘what happened?’ and ‘what were the circumstances?’ Such an approach may be the key to improving levels of patient care, as well as the professional and personal lives of veterinary personnel.

Worthy of the 'global leader' hype, or are we seeing the tip of the iceberg?

John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses some recent patient safety crises, litigation claims and a new patient safety publication from NHS Resolution.