Clinical negligence costs: taking action to safeguard NHS sustainabilityBMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m552 (Published 02 March 2020) Cite this as: BMJ 2020;368:m552
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Improvements in quality and patient safety might help to reduce litigation costs, but are we still allowed to invest for the future?
We read with interest the contribution  by Tim Draycott and colleagues and share their concern about the rising amount of resources that our National Health Services (NHS) are forced to divert from care to cover litigation costs. Theoretically, we also appreciate the proposal to adopt foundational principles for safer care in general, not only to tackle the problem of clinical negligence at source. However, we would like to raise some doubts regarding the practical application of these principles.
First, it should be emphasized that the current burden of litigation is the result of multiple factors, not all of which can be managed by adopting policies of quality and safety improvement (for example, prognostic misperceptions due to emotional and/or cultural factors or advertising campaigns that effectively guarantee compensation). Therefore, it is currently impossible to assess a priori whether the adoption of the principles that Draycott and colleagues propose would lead to a substantial reduction in the number of claims.
Second, if it is true that learning from the experience of when things go wrong is not enough to manage clinical risk, it is also true that adopting only safety 2 models could generate different forms of litigation in the future, because even the most virtuous processes have hidden pitfalls .
Finally, despite the increasing ‘use of mediation and other forms of dispute resolution to avert claims going to formal court proceedings’, the litigation burden is often the outcome of clinical negligence that occurred several years earlier: similarly, the effect of strategies aimed at reducing avoidable harms may not be immediate.
Such a latency could make the investments needed to realize the proposed strategies unpalatable to hospitals, that are increasingly managed with a business model that tends to favour short-term efficiency at the expense of forward-looking policies with unpredictable effects, even in light of our NHSs’ difficulties, which existed even before the COVID-19 Emergency .
 Yau CWH, Leigh B, Liberati E, Punch D, Dixon-Woods M, Draycott T. Clinical negligence costs: taking action to safeguard NHS sustainability. BMJ 2020;368:m552 doi: 10.1136/bmj.m552
 Wang F, Tian J, Lin Z. Empirical study of gap and correlation between philosophies Safety-I and Safety-II: A case of Beijing taxi service system. Appl Ergon. 2020 Jan;82:102952. doi: 10.1016/j.apergo.2019.102952
 Ricciardi W. La battaglia per la salute. Editori Laterza, 2019
Competing interests: No competing interests
Yau and colleagues draw attention to rising negligence claims and make some wise recommendations as to how clinical safety can be enhanced . However, the information held by NHS Resolution is an important resource ought to be used to instruct this process. This is hampered by the fact that only those cases that come to trial are in the public domain.
An example is when radiology is reported as showing evidence of possible lung cancer but that report is ignored. Diagnosis of this disease as a result of an incidental finding carries a prognostic advantage . An international benchmarking study showed that fewer UK and Danish patients have their tumour diagnosed by this route than some other countries . This is consistent with the relatively poor outcomes of lung cancer in these nations.
The Healthcare Safety Investigation Branch described such a case . Their report presents an analysis of Strategic Executive Information System which showed 41 delayed diagnoses of lung cancer occurred in a 58-week period. This can come from a wide variety of radiological procedures . The requirement to refer suspicious chest X-rays to the relevant multidisciplinary team was dropped from the 2019 iteration of Quality Standards for lung cancer.
The process of improving patient safety will benefit if lessons from all litigation where liability is accepted by NHS organisations are collated and patterns recognised.
1] Yau CWH, Leigh B, Liberati E et al, Clinical negligence costs: taking action to safeguard NHS sustainability BMJ 2020;368:m552
2] Quadrelli S, Lyons G, Colt H, Chimondeguy D, Buero A. Clinical characteristics and prognosis of incidentally detected lung cancers. International journal of surgical oncology. 2015; dx.doi.org/10.1155/2015/287604
3] Menon U, Vedsted P, Zalounina Falborg A, et al. Time intervals and routes to diagnosis for lung cancer in 10 jurisdictions: cross-sectional study findings from the International Cancer Benchmarking Partnership (ICBP)BMJ Open 2019;9:e025895. doi: 10.1136/bmjopen-2018-025895
4] Healthcare Safety Investigation Branch FAILURES IN COMMUNICATION OR FOLLOW-UP OF UNEXPECTED SIGNIFICANT RADIOLOGICAL FINDINGS I2018/015 2019. https://www.hsib.org.uk/investigations-cases/communication-and-follow-un... accessed 23/3/2020
5] Crawford SM. Make sure to act on radiological suspicions. BMJ 2019;364:l1049
Competing interests: No competing interests