Good morning and welcome to a slightly delayed patient safety update in which we give our take on the Ockenden Review and the latest amendments on the Health and Care Bill which finally got through the Commons last night only to go back to the Lords as well as an HSIB investigation into pulmonary embolisms. 

OCKENDEN REVIEW The final report is out and as I said in Parliament it is far worse than my darkest fears when I commissioned it in 2017. Donna Ockenden has done an extraordinarily thorough job, dividing up over 1500 investigations into the different stages of the birthing process - and laying out in black and white the willful refusal of the trust to investigate concerns time after time and the extreme dangers of an ideological approach to ‘natural birth.’ Most distressing for me was hearing that mothers were often blamed, sometimes for their own deaths, and that nine of the twelve mothers who died might have survived with better care. The Health Secretary did a pretty good job in his statement, and rightly said that the government accepts all the recommendations. Given they are described as ‘immediately essential actions’ the question is how immediately they will be implemented. But it was also a big victory (if I may say so) for the Select Committee whose recommendations from last summer were all included as immediately essential and will now be adopted. That must mean more than the £50m over two years for staffing given we called for additional funding of £200-350m per year. This thread covers this and my other main concerns and you can see a fuller statement here. My thoughts on how we finally break the cycle and learn from the mistakes that have been highlighted in this report and others are set out in this Telegraph article.

WORKFORCE AMENDMENT The encouraging news about maternity safety improvements only lasted so far though because on the big question of workforce the government yesterday again rejected the amendment to the Health and Care Bill that would mean independent workforce projections were published so we deal once and for all with the issue of not training enough doctors, midwives and nurses for the future. As I’ve said before I think this is reckless and shortsighted and as I told the House of Commons in my speech on the Bill yesterday the amendment would not only help the beleaguered workforce but it would also help the Treasury keep control of the out of control locum and agency staffing bill. We must now wait to see if the Lords put the amendment back in when they next consider the Bill on 5th April which I hope they do. Is there a possible ray of light in the Minister’s comments that the government “do not think it is necessary in its current form”? Perhaps but the private mood music was that the Treasury are totally dug in and today’s Times headline about Rishi Sunak’s anger with the OBR isn’t very encouraging when it comes to his views about bodies giving independent views.

HSIB AND CORONERS But there was some good news on the Bill amendments when there was a government change of heart on the role of coroners and the ‘safe-space’ provisions in HSSIB. The Lords amended the Bill so that coroners would not routinely have access to material provided under the safe space provisions meaning Coroners will now have to get a high court ruling to see the evidence transcripts. Initially the government had planned to reject this amendment but thankfully were persuaded to accept it after extensive lobbying by me, Philip Dunne, Bernard Jenkin and others of Dominic Raab, Tom Pursglove and the Chief Coroner. This is a very welcome decision and should hopefully mean that those giving evidence to HSSIB investigations can be open without fearing for any professional consequences - as works successfully in the airline industry. Separately HSIB have published a report on diagnosing ‘time-critical’ pulmonary embolisms which makes a number of useful recommendations to ensure more timely diagnosis. 

COMPOUNDED HARM An interesting research paper published a few days ago on ‘compounded harm’ is worth a read. This is the concept that the way investigations into adverse effects are carried out can compound the harm felt by patients, families and health professionals. It suggests ways to reduce this mainly focused on a restorative justice approach which you will know I have long supported.

COVID LATEST The increase in cases may have peaked at 1 in 16 people having the virus in the week ending 19th March. Interestingly this is about the same level as in Northern Ireland and Wales but in Scotland the figure is even higher at 1 in 11. I say ‘peaked’ because the Dashboard has the number of cases having fallen in the last seven days by 7% and the ONS usually picks these trends up a week or two later. In England the number of people being admitted to hospital each day has also doubled in the last month which has taken the total number in hospital with Covid from 11,000 at the start of March to nearly 18,000 now. Patients on ventilators is still low but is rising slightly.

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Jeremy Hunt