Emergency Department Insights: Closing the loop: learning from harm

Date published:

On 27 March 2023, NHS Resolution held an insights event, “Closing the loop: learning from harm” for the North West region at Manchester University NHS Foundation Trust. The focus was on learning from Emergency Department (ED) claims.

The event was supported by the regional panel: Hill Dickinson, Hempsons and Weightmans, and provided an opportunity to measure the impact of our 2022 thematic reviews on ED claims.

We were joined by Dr Chris Moulton and Sue Greenhalgh from Bolton NHS Foundation Trust who provided an excellent update on the work they have done to reduce risk at their Trust, particularly in the area of Cauda Equina diagnosis and the importance of using simple language to help staff identify red flag symptoms. Dr Moulton is also the Lead for Emergency Medicine and Integrated Urgent and Emergency Care, Getting It Right First Time (GIRFT) and provided an insightful summary of the new SEDIT process which uses data metrics to drive performance improvement in ED.

This was followed by another fascinating session with Dr Ron Daniels, who is Chair of The UK Sepsis Trust and a practising intensive care unit doctor. He described how sepsis claims around 47,000 lives a year in the UK and shared the work the charity has done to raise awareness of the key symptoms through targeted advertising. NICE guidelines are expected on this very soon and all are encouraged to implement them fully when published.

The second half of the event took the form of a World Café, with three stations, each focused on one of the three ED reports: sepsis (high value and fatality review), missed fractures and frailty (hospital acquired pressure ulcers and falls review). This was a valuable opportunity for delegates from legal and governance teams as well as practising clinical staff to describe the particular challenges they face locally, the actions they have taken to reduce risk and what they might be able to do in the future to avoid similar harm.

It was fantastic to hear of all the quality improvement projects that have been implemented across the system as well as demonstrate the value of our contribution in this area.

To continue to promote the recommendations from the reports, we are pleased to announce that NHS Resolution are holding a national emergency medicine conference on Monday 9 October 2023, Implementing recommendations: Shared insights to reduce claims in Emergency Medicine programme. The conference will bring together professionals working in emergency departments across England. We’ll be hearing from key speakers from Getting it Right First Time, The Sepsis Trust, The Society and College of Radiographers, Royal College of Emergency Medicine and others. Trusts are also invited to share best practice examples of how they’ve made changes locally to deliver better care for their patients through entries to our poster presentation competition.

To register and find more information about this free national emergency medicine conference, visit our event page.