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Written on 30th March 2022 by

The NHS defence organisation, NHS Resolution, has published its report into medical negligence emergency department (ED or A&E) claims arising from patients’ deaths or life-changing injuries. The ‘High value and fatality related claims’ report is one of three thematic reviews into compensation claims brought by patients who were injured by negligent NHS emergency care in England between 2014 and 2018.

The review looks at 86 claims arising from the death of the patient, and 16 claims for life-changing, severe injury, described as ‘high-value’, in which the patient’s compensation was over £1 million.

The 86 settled fatal injury claims had a combined cost of £5.8 million, with an average compensation payout to the patient’s family of just over £45,000. Common causes of patient deaths included misdiagnosis of infection or sepsis, pulmonary embolus (PE), falls in hospital, and cardiovascular heart conditions. Patients also died as a result of medication errors and failure to prevent venous thromboembolism (VTE).

The 16 ‘high value’ claims had a combined cost of £33 million, with average individual settlements of just over £2 million. Missed diagnosis and failure to investigate featured in all the ‘high value’ claims, especially those relating to spinal cord injury (SCI) and brain injury

Emergency medicine and negligent A&E or ED care

Emergency medicine has had either the highest or second highest number of new claim notifications to NHS Resolution every year for the past ten years. In 2020/21 ED claims accounted for 1,151 or 11% of all medical negligence claims reported to NHS Resolution with an estimated cost (in compensation and legal fees) of just under £322 million. Between 2010/11 and 2019/20 there has been a 17% rise in A&E attendances and a 23% rise in A&E claims. According to NHS Resolution, claims arising from NHS emergency care are still low when compared with A&E attendance rates, at one claim for every 17,000 episodes of ED care.

A&E or emergency departments face significant challenges, as an ‘always open’ service providing care for a wide variety of acute and urgent illnesses and injuries in patients of all ages in many different states of health. A&E must meet the needs of a population that is growing, ageing and increasingly complex, with many patients having pre-existing conditions as well as the problem for which they are attending. The demand on emergency medicine is high and continues to grow year on year.

According to NHS Resolution, a recent review of emergency medicine by Getting It Right First Time (GIRFT) found ‘enormous unwarranted variation in Emergency Departments throughout England’, as a result of geographical, demographic, historical and funding issues, problems with systems and processes, and EDs failing to meet the local demand for emergency care. GIRFT also highlighted patient outcomes and experiences as a major concern during their review of NHS emergency care.

Themes from NHS Resolution’s review of severe and fatal injury claims from emergency care

Common themes that were associated with causing high levels of harm to patients from negligent emergency care included:

  • failings in the investigations process, leading to missed or delayed diagnosis;
  • failure in recognising and responding to patients who were deteriorating or who re-attended hospital;
  • an overarching issue with providing patients with timely, proper review by senior clinicians.

Spinal cord injury

Patients’ conditions included traumatic spinal cord injury (SCI), tumours, haematoma, abscesses and cauda equina. Despite nearly all these patients having previously attended their GP or hospital on multiple occasions, NHS Resolution found little evidence that any were reviewed by a senior clinician when they attended for the second, third or fourth time with the same problem.

Claims involving misdiagnosis, particularly where important features of the history and examination had been missed, invariably led to compensation.  Failings included not identifying or giving enough importance to severe and persistent pain, failing to perform diagnostic tests, such as scans, and delays after diagnosis, such as in performing a scan or surgical intervention. Delays were due to lack of awareness of the urgency, or lack of MRI scanning facilities, or problems with communication and escalation between different specialties.

Brain injury

Patients suffered brain injuries from stroke due to carotid artery dissection, haemorrhage and meningitis. None of the patients had a typical history but correct history taking from all available sources should have led to correct diagnosis. NHS Resolution found that ambulance and triage notes and GP letters accompanying patients were not available or read by their treating doctors, conditions were misdiagnosed, and even after diagnosis long waits for review from more senior or different specialty doctors led to delays in scanning and interpretation.

Death from pulmonary embolism (PE)

Fatal claims following death from PE arose from hospital-caused (iatrogenic) harm and missed diagnosis, often related to immobilisation after their injury, lack of risk assessment for thromboembolism and failure to recognise signs of DVT or pulmonary embolism.  

Death from sepsis

Failings in emergency department care which led to diagnosis and treatment of sepsis included failing to recognise or act on abnormal test results or x-rays, prolonged waits for assessment, failing to carry out proper tests and misdiagnosis. Emergency staff also failed to act on handover information from paramedics or GPs, delayed giving antibiotics owing to failing to consider sepsis, and failed to escalate the patient’s treatment to the intensive care unit.

Death from aortic disease

Patients died after ruptured abdominal aortic aneurysm (AAA) and aortic dissection, even though these conditions are known to require prompt investigation, identification and treatment.  In these cases there was often a  misunderstanding of the significance and high risk associated with abdominal pain in older patients, poor communication and escalation to a consultant in time to allow prompt intervention.  RCEM guidelines intended to reduce the risk of missing life-threatening conditions (such as AAA or aortic dissection ), such as by imaging or review, were not followed in any of these cases.  

Death from cardiac (heart) conditions

Patients who died from heart conditions, such as acute coronary syndromes or ventricular tachycardia, all had abnormal tests, such as ECGs, which were either not recognised, not reviewed and/or not acted on. Patients died either before clinical assessment, after a lengthy stay in A&E or after being discharged. In some cases, busy departments meant that patients were  cared for outside of the recommended environment, leading to delays in proper care.

Deaths from bowel conditions

Common themes in the claims arising patient deaths from bowel conditions, such as perforation and peritonitis included failure to recognise the significance of severe pain, failing to request diagnostic tests or act on abnormalities in test results, and failing to escalate deteriorating patients or arrange specialist review. Other errors included poor communication about treatment options with the patient and poor diagnosis and planning at time of discharge.

Medication errors

Patients died as a result of being given excessive doses of morphine, or being given medication intended for a different patient. Deaths were also caused by giving the patient a drug to which they were allergic or failing to give them their regular prescription drugs and then failing to manage their resulting deterioration.

Help with medical negligence claims following death or life-changing injury

Each claim featured in NHS Resolution’s review reflects an individual who was left with severe disability or who lost their life as a result of failings in care and avoidable error. We welcome this review, in the hope that the NHS at all levels can learn from these mistakes, so that fewer patients will suffer similar avoidable harm in the future. Meanwhile Boyes Turner remain committed to helping severely injured patients and their families rebuild their lives, recover their independence and provide security for their future. We do this by helping our clients to secure the care, therapies and equipment they need and adapt their homes to suit their disability, by recovering their full entitlement to compensation.

If you or someone in your family have suffered severe disability and would like to find out more about making a claim, you can talk to one of our solicitors, free and confidentially, by contacting us here.