Feature Compensation

The long road to ensuring patient safety in NHS hospitals

BMJ 2013; 346 doi: https://doi.org/10.1136/bmj.f3029 (Published 23 May 2013) Cite this as: BMJ 2013;346:f3029
  1. Clare Dyer, legal correspondent
  1. 1 BMJ, London WC1H 9JR
  1. claredyer4{at}gmail.com

As part of a series on compensation for clinical errors, Clare Dyer looks at efforts, past and present, to monitor and prevent mistakes that harm patients

In 1995, 18 month old Joshua Loveday was scheduled to undergo a complicated “switch” heart operation at Bristol Royal Infirmary. But behind the scenes, desperate last minute attempts were being made by an anaesthetist, a surgeon from outside Bristol, and a senior official from the Department of Health to persuade the hospital not to go ahead with the operation. Unknown to Joshua’s parents and the public generally, figures kept by Bristol anaesthetist Stephen Bolsin suggested that the hospital’s mortality rates for such operations were much higher than those at other units. The operation went ahead anyway, and Joshua died on the operating table.1

His death led to a public inquiry, which in 2001 found that 30 to 35 more babies under 1 year old died having open heart surgery at Bristol between 1991 and 1995 than would have died if they had had their operations at a typical unit. The mortality rates for children under 1 year were probably double the rate in England as a whole, the inquiry found, and even higher for children younger than 30 days.2 Bristol’s poor results were an open secret in the hospital: Bolsin had been trying to raise concerns about them for years. In the end, he found himself frozen out in the UK and took a job in Austrialia. At the Bristol inquiry, the chair of the regional health authority responsible for the Bristol Royal Infirmary admitted that from the data available she would not know how many patients had died in a particular hospital; her concern was “throughput.”

Spool forward to 2013 and the day after NHS England’s medical director Bruce Keogh …

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