Medway NHS Foundation Trust review raises concerns about patient safety investigations

Patients should be able to trust that hospitals will investigate serious concerns about their care. Recent reports suggest this did not always happen at Medway NHS Foundation Trust. 

The Trust has reported a backlog of 113 patient safety incidents requiring investigation or further action under the NHS Patient Safety Incident Response Framework (PSIRF). It also confirmed that 428 patient safety incidents remain open.  Board papers said 113 investigations were closed without what they called a ‘proper investigation’. The Trust has since brought in external support to help address the backlog and strengthen its processes.  

You need confidence that healthcare organisations will investigate when something goes wrong. A thorough review can help explain what happened and identify changes that could improve patient safety.

The Trust identified 59 cases where there was little or no evidence that it had followed the NHS duty of candour process. This process is designed to ensure patients are told openly when something has gone wrong with their care. The Trust has since said it has completed the duty of candour process, or found evidence that it had already been completed, in 45 of the 59 cases. It added that it is actively progressing the remaining cases.

You deserve to feel confident that their concerns will be heard. The independent review found that changes were needed to improve how patient safety incidents were managed at the Trust. 

The review, carried out by former chief nurse and improvement director Steve Lennox, raised concerns about the culture around patient safety. It found that some members of the governance team had a “nothing to see” approach towards potential patient safety cases. The review also identified a lack of trust and confidence between some individuals and teams. Some clinicians said that learning identified from incidents had been changed during the governance process without explanation. 

Mr Lennox said it was important for clinical staff to feel they could make a difference and help improve patient safety. He also highlighted concerns from clinicians who questioned why some serious incidents, including one involving a patient death, did not require a full investigation. 

The Trust has accepted the findings of the independent review and is carrying out its own review of how it uses the Patient Safety Incident Response Framework. 

Chief Nursing Officer Evonne Hunt said the independent review identified issues with how patient safety incidents were managed and the culture needed to support effective learning. She said: “Our focus is ensuring concerns are investigated promptly, learning is shared consistently, and the changes needed to improve the safety and quality of care for our patients are implemented.” 

The Trust said it has strengthened executive oversight and clinical leadership of patient safety. It has introduced stronger governance arrangements and improved training and data quality. 

When questions remain about your care, it can be difficult to know where to turn. You may still be looking for answers about what happened and whether it could have been prevented. 

Our specialist medical negligence solicitors have extensive experience supporting people affected by failures in hospital care. We understand the impact that delayed investigations and poor communication can have on patients and their families. 

 If you believe you or someone you love has been affected by poor medical care, we’re here to help. Our team can explain your options clearly and answer your questions. We can give clear advice on whether you may be able to bring a medical negligence claim. 

To find out more, visit our medical negligence page or contact our team today.