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Shared Insights: Learning from operating theatre claims and the challenges of service recovery post-pandemic

14 July 2021

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The first part of this Shared Insights session was led by Sharon Fletcher, Associate Safety and Learning Lead at NHS Resolution who, prior to the pandemic, started some work looking at the themes and learning arising from Operating Theatre claims between 2010 and 2020.

We were also delighted to be joined by Mr Arthur Stephen, Consultant Orthopaedic Surgeon and Divisional Director for Surgical Services at University Hospitals of Derby and Burton NHS Foundation Trust (UHDB). Mr Stephen chairs the Trust Harm Review Committee at UHDB and is the lead for surgical service recovery at UHDB. He led a discussion about the challenges faced by NHS Trusts as they seek to restore surgical and other services post-pandemic.

The Shared Insights were:

Looking back to enhance learning

Sharon’s thematic review looked at 13,451 claims relating to operating theatres following incidents that occurred 1 April 2010 to 31 March 2020.

Key themes included:

  • Inadequate documentation
  • Lack of quality handover from Operating Theatre and Recovery Room to the ward
  • Poor communication
  • Inadequate Nursing/Operating Department Practitioner (ODP) care 

What can we learn from these claims?

  • There are already lots of theatre safety initiatives in place (e.g. WHO surgical checklist, National Safety Standards for Invasive Procedures (NatSSIPs) and Local Safety Standards for Invasive Procedures (LocSSIPs)). However, it is important that Trusts design systems that take into account human factors.
  • Engagement with teams is key to understand what works well, recognising that Covid-19 has added an extra layer of distraction/fatigue/stress.
  • An understanding of human factors is vital and will support learning from near misses as well as incidents.
  • Trusts need to have a just and learning culture and staff should be supported to learn from their actions when things go wrong - see NHS Resolution Being Fair Report for guidance.

Key Takeaways

  • Celebrate what you/we do well and keep doing it. Maintaining quality for services.
  • When things don’t go to plan ensure that there is a restorative, open and honest approach to the patient, family and staff.
  • Put information into context. Learn from excellence, share compliments and support each other in a Just and Learning culture

Looking ahead

  • Mr Stephen highlighted the challenges that Trusts are facing in the wake of the pandemic including the enormous back-log of patients who are still waiting for surgery (with many routine procedures now more complex); staff who are close to burn out, many of whom are still off work isolating or sick; and the return to nearly 100% GP referrals so waiting lists are growing.
  • Restoration is the key. Whilst redesign could be considered in future, it is not the answer now.
  • Legal input in decision making on various issues including the prioritisation of patients during this period has been hugely important and needs to continue. It is vital that Trusts document the decisions that have been reached and the context, justification/rationale in as much detail as possible for retrospective review. Documentation needs to be retained and be accessible in the future.
  • NHS E&I has provided some guidance on this for NHS Leaders in the context of preparation for the Statutory Inquiry into Covid-19
  • In addition to the importance of good documentation of the high-level decisions, it is important that clinicians ensure that record keeping for individual patient records is comprehensive (including, for example, records of telephone discussions) and clear, providing any relevant context to decisions made about treatment.
  • We also had an interesting discussion about the potential impact of the pandemic on the claims landscape and the ongoing challenges faced by the NHS, including a discussion as to how the courts might approach this. The position is not clear at the moment but there is law on “battlefield conditions” and this is another reason why documentation is so important, to provide the context at the relevant time.

Shared Insights

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Nicola Evans


+44 (0)330 045 2962

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Damian Whitlam


+44 (0)330 045 2332

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