Sir Liam Donaldson said that the safety record of all health trusts should be made public to help to ensure that they comply with patient safety alerts promptly. A trust’s record should form a major part of its yearly performance rating.

In his annual report on public health, Sir Liam said that the NHS had yet to embrace the culture of patient safety, with some trusts taking years to implement alerts put out as a matter of urgency. Some trusts that were reported to be following national advice were subsequently found to be failing.

Patient safety alerts, which are issued on matters such as the use of equipment and drugs and are intended to minimise human error, are sent to all NHS organisations. About

10 per cent of patients admitted to hospital are thought to suffer some form of medical mistake.

Comparing the NHS with the airline industry, where safety had been a central focus since the 1960s, the report concluded: “It is only relatively recently that attention has been focused on the safety of patient care as an issue.

“Despite the relatively high level of risk associated with healthcare, systematic attempts to improve safety and the transformations in culture, attitude, leadership and working practices necessary to drive that improvement are only just beginning.”

He said that, in some cases, compliance with safety alerts had started only after high- level intervention from the Department of Health, including warning letters and meetings with hospital managers.

Sir Liam highlighted several cases where patients had died as a result of an error, including a girl aged 3 who was given nitrous oxide instead of oxygen from an anaesthetic machine. Another alert was issued over intrathecal chemotherapy — injections into the spine given to treat cancer. Wayne Jowett, a teenager from Nottingham, died in 2001 after a drug was injected into his spinal fluid rather than intravenously.

Sir Liam said that after guidance on intrathecal chemotherapy was introduced later that year, NHS trusts had to complete a checklist confirming compliance with the advice by the end of December 2001.

By March 2002, some 32 NHS trusts (21 per cent) remained non-compliant and it was not until the summer of 2003 that full compliance was achieved.

Revised guidance was issued in October 2003, but it was not until this January that all trusts were reporting compliance, after warning letters and phone calls to chief executives. But an independent review found that not all the trusts were following the guidance. “Of the nineteen NHS trusts providing intrathecal chemotherapy services that had been reviewed by April 2005, nine were non-compliant on inspection, despite three of these having claimed compliance prior to the inspectors ’ visits,” Sir Liam’s report said.

“These trusts are now either compliant or no longer providing an intrathecal chemotherapy service. So serious were some of the breaches that services were suspended.”

Sir Liam said that the slow pace at which trusts responded to the guidance —and in some cases said they had responded but were found not to have — showed that the safety culture in the NHS was not yet focused or organised enough to reduce a potentially fatal risk to patients quickly enough. “If the local NHS wants to have autonomy then their part of the bargain is that they have to meet important national standards.” He added: “In some cases they need to meet them quicker than they are doing.”

SIR LIAM'S CALLS TO ACTION

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