Hospitals’ disregard of patient safety alerts is risking lives, claims charity

BMJ 2010; 340 doi: (Published 17 February 2010) Cite this as: BMJ 2010;340:c984
  1. Adrian O’Dowd
  1. 1London

NHS trusts in England are failing to act on mandatory patient safety alerts issued by the National Patient Safety Agency and are leaving patients open to risk of harm, says a leading patient safety charity.

Action Against Medical Accidents (AvMA) said it had gathered evidence showing that 307 NHS trusts (around 75% of all trusts in England) had not complied with the required actions in at least one patient safety alert before the deadline specified by the alert.

The charity, which supports thousands of people who have been affected by medical accidents, has this week published a report on NHS bodies’ failure to implement patient safety recommendations issued by the National Patient Safety Agency.

The report is based on information gathered under a Freedom of Information request that the charity made to the Department of Health, which manages the central alert system.

The data covered 53 patient safety alerts issued between 2004 and 2009 to all relevant NHS trusts in England.

After the charity sent the report and attached recommendations to the health minister Ann Keen the health department responded by saying it would issue a reminder to all trusts about their responsibilities in this area.

From its research into the 53 safety alerts the charity found:

  • 2124 separate incidents of NHS trusts not complying with patient safety alerts, and

  • More than 200 incidents of NHS trusts not having complied with alerts that were more than five years old.

A particular concern raised by the charity was the fact that no coordinated system exists for monitoring implementation of alerts or of intervening against NHS trusts that have not implemented the actions required by the alerts.

Details of particular cases were given on the BBC Radio 4 programme File on 4 this week (

The report recommends that the health department and the Care Quality Commission, which regulates the NHS, investigate patient safety arrangements at trusts that have not implemented large numbers of outstanding alerts and that a robust system for monitoring compliance with alerts be introduced.

The charity’s chief executive, Peter Walsh, said: “The fact that so many NHS bodies are failing to comply with potentially life saving alerts is shocking. It is putting lives at unnecessary risk and adds insult to injury for patients who have been harmed or lost loved ones as a result of NHS lapses in safety.

“There is an issue of clinical leadership and making sure that these safety alerts are undertaken securely.”

The National Patient Safety Agency’s director of patient safety, Suzette Woodward, said, “We acknowledge the main findings within the report. Delivering high quality and safe services to patients is the top priority of the NHS and the NPSA. It is vital therefore that all NHS organisations comply with these alerts to ensure the highest levels of safety for all their patients.”

A health department spokeswoman said, “From April, all NHS trusts will be required to register with the Care Quality Commission. From this point it will be mandatory for NHS organisations to report serious patient safety incidents, improving identification and monitoring of incidents.

“We expect all NHS trusts to comply with safety alerts and to record and action them.”


Cite this as: BMJ 2010;340:c984