NHS Resolution has today published a set of three reports which explore clinical issues that contribute to compensation claims within Emergency Departments.
Emergency Departments (ED) in England provide a high-quality service to patients under challenging circumstances. It is understanding how claims can provide unique learning to enhance safety and patient experience further which these reports aim to deliver. We acknowledge that they are published at an almost unprecedented time for the NHS, which remains under enormous pressure from the Covid-19 pandemic. Although the claim numbers for emergency medicine are higher than almost any other clinical specialty they are very low when considering how many people come to ED for treatment every day.
In total, 220 cases were examined, where the incidents occurred between 2014 and 2018 and a legal liability had been established.
The first report looks at high-value and fatality-related claims over £1m; the second report assesses missed fractures; and the third report evaluates hospital-acquired pressure ulcers and falls in ED. Each report also contains clear recommendations to help prevent further incidents. One of the main findings across all the reports is that ED clinical services should provide timely identification of diagnoses and treatment plans for patients. This should include what to look out for and actions that should be taken if the patient deteriorates. Good record-keeping and communication to support handover and ‘safety netting’ for patients – where they are followed up in a timely and appropriate manner – underpins the delivery of timely diagnoses and the delivery of effective treatment plans.
The other key clinical issues the reports highlight are:
- access to senior staff review, with appropriate use of multidisciplinary teams working between specialties;
- systems in place for prompt clinical imaging;
- infrastructure for appropriate escalation and handover of clinical details to senior clinical staff and specialist clinicians respectively;
- identification and proportionate clinical strategy regarding patients who regularly attend ED; and
- the benefits of digital solutions to support timely and appropriate clinical decisions for patients.
These reports provide analysis of claims of patients who have attended Emergency Departments in England and highlight important details to support the delivery of holistic care. The recommendations aim to make it easier for clinicians to do the right thing to support patient healthcare planning, and enhance safer care and patient experience.Helen Vernon, Chief Executive, NHS Resolution
The number of claims is relatively small compared to how many people attend emergency medicine, although attendances are increasing year-on-year, and patients have more complex needs.
NHS Resolution has worked in partnership with other organisations, including the Royal College of Emergency Medicine, the Royal College of Nursing, and NHS England and NHS Improvement, in preparing these reports.
Helen Vernon added: “These reports would not have been possible without input from the members of our Clinical Advisory Groups, none more so than Dr Cliff Mann OBE, GIRFT Clinical Lead for Emergency Medicine. Dr Mann sadly passed away in February 2021 and as an advocate for the speciality of Emergency Medicine and a leader in the NHS he will be sorely missed.”
The Royal College of Emergency Medicine welcomes these reports as learning opportunities to reduce the tragedy of preventable harm to individuals and their families as well as the staff involved. As specialty leaders and standard setters, we must use the stories and themes identified in these reports to focus our guidance and teaching and sharpen our advocacy for a better system of care modelled to deliver patient needs.Dr Katherine Henderson, Royal College of Emergency Medicine President
This set of reports is a valuable source of learning for health and care services, and for nursing, beyond the front door, as the themes identified here resonate more widely. The third report in this series focuses on pressure ulcers and falls, which are recognised as nurse-sensitive indicators of quality care. The Royal College of Nursing has published Nursing Workforce Standards which apply across all settings, and are designed to support a safe and effective nursing workforce wherever care is delivered.Rachel Hollis, Chair of Royal College of Nursing’s Professional Nursing Committee
Notes for editors
- For the past ten years, emergency medicine (EM) as a specialty has occupied either the first or second position each year in terms of the highest number of new claim notifications to NHS Resolution. While the figures for EM are high in the context of claims, they are very low in relation to overall activity in the ED, with a claim occurring for only one in every 17,000 episodes of ED care.
- Despite the large and increasing demand on emergency departments the number of claims have risen broadly in line with the rising number of attendances to ED (17% rise in attendances, 23% rise in EM claims between 2010/11 and 2019/20). While this should be treated with caution due to the lagged nature of claims and the influence of the legal market (with claims overall peaking in 2013 due to legal reforms), the trend observed does not give reason to suggest a deteriorating picture in regards to either patient safety or claims risk in this area.
- Key conclusions across three reports from Emergency Medicine series:
- Diagnostic errors including missing signs of deterioration, particularly for spinal and cerebral injury
- Failures in the investigation process leading to missed or delayed diagnosis
- Failure to recognise the significance of re-attendance to ED
- Delay in accessing senior and specialty reviews, leading to missed therapeutic options
- Communication issues impacting the escalation and handover of care and cross specialty team working
- Absence of standardised risk assessments
- Failure to deliver proactive nursing interventions in ED, leading to harm
- Inconsistent use of incident reporting and investigations as tools for learning from harm to make care safer
- Diagnostic error, specifically where early incorrect diagnosis prevented further investigation
- Obtaining images to support diagnosis, including requesting, reporting, interpretation and follow up of images.