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Good morning and welcome to my 2020 review of patient safety. Difficult to know quite where to start given that in the last 12 months we’ve had 1 global pandemic, 2 select committee reports, 3 independent reviews into patient safety, 7 immediate and essential actions on maternity safety, 17 patient safety recommendations to government, 27 local actions for learning on maternity safety, 58 recommendations or conclusions from the select committee, 515 HSIB maternity investigations, more than 70,000 COVID-19 deaths in the UK, and nearly two and a half million cases. Quite a year. Below are just some of the major events that took place in each month of 2020. January I became Chair of the Health and Social Care Select Committee but rather more importantly the first two cases of COVID-19 were confirmed in the UK. February The government appointed Bill Kirkup to lead an independent review into East Kent Maternity Services after reports of dozens of baby deaths and more than 100 babies suffering from brain injuries across the Trust. March On 26th the first national lockdown started designed to reduce the spread of COVID-19 and ensure the NHS wasn’t overwhelmed. It succeeded. However the government stopped community testing for the virus despite evidence from around the world and advice to the contrary from the WHO. April HSIB published its summary report into East Kent Hospitals. The Health Secretary set and met (sort of) a capacity target of 100,000 COVID-19 tests per day and SAGE modelled test and trace as a possible way to tackle the virus for the first time. May The Prime Minister announced the relaxation of some of the lockdown restrictions allowing people to meet in groups of six outside and an easing of the rules for those shielding. SAGE papers highlight how nearly 20% of hospital cases of COVID-19 were acquired from within hospitals. They still are - not least because weekly testing of NHS staff wasn’t introduced till November. June NHS Test and Trace is launched and in its first week identified more than 31,000 contacts of whom 26,900 were reached and asked to self-isolate. The Prime Minister appeared in front of the Liaison Committee and pledged there would be a 24 hour turnaround target for COVID-19 tests (something that has still yet to be met) and assured us that agency staff were banned from working in more than one care home (something that is still not the case). July Julia Cumberlege published the final report of the Independent Medicines and Medical Devices Safety Review. This looked at the harm caused by three issues - Primodos, sodium valproate and pelvic mesh - and highlighted 9 recommendations that would improve patient safety. The Select Committee inquiry on maternity safety was launched and an inquiry on workforce burnout was also started. August HSIB published its annual review highlighting how it had completed 15 national reports, 515 maternity investigations, and made 58 national safety recommendations. September The second ever World Patient Safety Day was held with a focus on healthcare worker safety. 105 countries marked the day and monuments or landmarks in more than 80 cities were lit up. It was also revealed that maternity litigation cost the NHS £1bn a year. October Two Select Committee reports were published. Firstly on Delivering Core NHS and Social Care Services in the Pandemic which made a strong recommendation for the implementation of regular testing of NHS staff. Sadly we had to wait more than a month for this to actually happen. The second report was on social care funding and workforce which called for a £7bn annual increase in funding as the starting point for reform. Baby Loss Awareness Week was also marked. November Bill Kirkup published his report into the Life and Death of Elizabeth Dixon detailing the avoidable mistakes that caused her death and the near 20 years of cover ups that kept the truth from her parents. Bill outlined 12 recommendations that need implementing urgently. Pfizer announced that its vaccine is more than 90% effective against COVID-19. December The UK became the first country in the world to licence a clinically-approved vaccine for Coronavirus in a major triumph for British science, the vaccines taskforce and Matt Hancock personally. Margaret Keenan became the first patient to receive it. However the Ockenden Review interim report was published painting a truly shocking picture of failures at the maternity services of the Shrewsbury and Telford Trust including the promotion of ‘normal birth’ ideology over many years. The report contained 27 local actions for learning and 7 Immediate and Essential Actions. New Year’s Resolutions it won’t surprise you that I have a few, so here goes: publication of long term workforce requirements for the NHS and social care system so we can make sure we are training enough doctors and nurses; putting HSIB on the statute book so it can offer healthcare staff a safe space to talk about things that have gone wrong as in the airline industry; a 10 year plan and funding for the social care system which is unfinished business for me after securing it for the NHS; reforms to end the blame culture which stops learning from tragedies, particularly in maternity safety; measures to tackle the 2000 people with autism/learning disabilities still practically imprisoned in ‘locked rehab’ units that should be closed down. A timely reminder that we have much to work for in 2021 - thank you in advance for all your support! Jeremy Hunt
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