Healthcare Providers are "High Reliability Organisations", which means that they routinely deal with high levels of risk and complexity. But it also means that even minor errors could have catastrophic consequences. What happens then, when serious errors are repeated and compounded by inadequate incident reporting?

A recent report has looked at the failings of a Norfolk hospital that caused the deaths of three patients with learning difficulties and has prompted calls for a review to prevent further lethal outcomes at similar facilities. The report highlighted a catalogue of significant and repeated failures by Jeesal Cawston Park, Norfolk, including excessive use of restraint and seclusion, unqualified staff, unsafe grouping, overmedication of patients, and "indifferent and harmful hospital practices" where questions and distress were ignored.

The hospital was closed in May 2021 after consistent failures to meet standards, and the operator, Jeesal Akman Care Corporation, went into liquidation in June, owing almost £4m. The report makes for distressing reading in that it did not highlight an isolated, tragic mistake or one-off event, but a catalogue of repeated errors. The death of Joanna Bailey was one such example in that she was not checked for two hours on the night she died, despite 30-minute checks being in her care plan, and a registered nurse and five care workers did not attempt resuscitation when she was found unresponsive in bed. The report also went on to describe how hospital records of her care were "unaccountably inadequate.”

Events like these are of course uncommon in the UK, but they nevertheless still happen too frequently in inpatient healthcare units that aim to help some of the most vulnerable members of our society, and the issue lies squarely with the hospital’s failure to properly report serious incidents, properly manage the risks identified by those incidents and properly manage and monitor the right actions to address them.

For example, the care plan for Joanna Bailey required staff to check on her every half an hour, and to ensure the regular use of a CPAP machine that aided her breathing at night, but where were the checks to ensure those actions had been taken? By failing to ensure that the required process was being followed correctly, the hospital allowed repeated lapses to go unnoticed, unchallenged, and uncorrected until they contributed to the tragic and entirely preventable death of a patient.

Jeesal Cawston Park’s failure to keep adequate hospital records were also a direct contributing factor. By failing to properly report incidents, staff and management alike failed to identify the serious risks that posed a danger to the health and wellbeing of the patients. With an easy, robust incident reporting system in place, the correct actions could have been planned to address those risks and mitigate or eliminate them promptly.

The lessons to be learned here are harsh but valuable, and the failures of Jeesal Cawston Park highlight the vital need for robust quality assurance management, observations, audits, risk management and incident reporting systems. NHS Trusts are already stretched to breaking point in an effort to manage the record-breaking waiting lists caused by COVID, so it’s more critical than ever that they use the best available tools at their disposal to maintain top levels of patient care and safety.

Robert Hobbs

Chief Executive Officer

InPhase’s Chief Executive and Founder, Robert has been the visionary leading InPhase to be one of the UK's leading providers of management, governance and assurance solutions, and helping organisations align their actions and goals more easily and efficiently with InPhase's suite of integrated apps.