The NHS is being urged to learn lessons from inquiries into poor patient care.
A lack of leadership, inadequate team-working and focusing too much on targets emerged as common themes in the Healthcare Commission’s review of 13 investigations between 2004 and 2007.
It said poor leadership was a problem in nearly all of the probes it carried out over the three years.
Some boards were also focused on mergers or targets at the expense of patient care.
Recent high-profile reports include those on Maidstone and Tunbridge Wells Hospitals NHS Trust and Sutton and Merton Primary Care Trust.
At Maidstone, appalling hygiene standards contributed to more than 90 deaths from the bug Clostridium difficile.
Meanwhile, at Sutton, the commission found serious neglect of people with learning disabilities.
The Learning from Investigations report out today also noted a lack of clarity on who was responsible for some procedures.
Other themes from the investigations were:
- some trusts experienced frequent changes in management which impacted on the quality of care. Bullying and harassment by managers was a factor in two of the reviews. The Commission said there was a ‘fine line’ between promoting change vigorously and bullying.
- poor teamwork, either between management and clinicians or clinicians themselves, was a common factor in why trusts failed to do their job properly.
- most trusts did not have adequate systems in place to routinely inform the board of trends or potential problems.
- seven of the trusts investigated had recently undergone mergers or significant organisational change.
- poor understanding of protection procedures for vulnerable adults was a serious problem in two investigations and a number of interventions in trusts.
- care on general wards fell well below the care provided on specialist wards in acute care. Older patients were most at risk as they depend on good nursing care.
- The commission conducted two investigations into learning disability services, three into maternity services, two on infection control and two into bullying and harassment. Other investigations covered specific areas such as gastroenterology, cardiac services, management of medicines and emergency care.
The commission urged senior managers to learn lessons, including seeking opinions from frontline staff about safety as well as ensuring proper reporting systems from the ‘ward to the board’.
NHS medical director Sir Bruce Keogh said: ‘Every NHS organisation must have an unrelenting focus on the safety and quality of care provided to its patients.
‘A strong regulator is not a substitute for strong clinical and managerial leadership at the local level, and when problems arise, as in the minority of cases highlighted in this report, NHS managers and clinicians need to work closely together to take action.
‘The new Care Quality Commission will build on the work of the Healthcare Commission, the Commission for Social Care Inspection and the Mental Health Act Commission, using tough new powers to assure quality and safety for patients and service users.’
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