Posted By Robert K Lewis The other figure of 980,000 incidents and near misses also interests me, it seems that there is a lot of data awaiting investigation and some effective corrective action taken. I think the NHS etc actually need some applause for their courage to allow any open reporting of the information. To use enforcement may actually make the whole problem worse. I know this runs against the grain of many who believe a breach must induce a hefty penalty but just imagine the staff reaction when the budgets are cut due to a massive fine and they have to work harder with less resources - hence producing more errors. This time they will not report and more will die unnnoticed due to clinical errors. As for CM - I do not think that there are matters of GROSS negligence as it is clear that trusts etc are working actively to find solutions to an intractable problem. Standing by for ripostes. Bob

Posted By steven bentham I know that to punish the health services for the people they have 'lost' will affect their resources; but if Education had 2000 fatalities a year I am sure we would be a bit upset, if the construction or railways killed 2,000 a year we would be demanding prison and fines; so whats the difference? Somehow these 2,000 don't come under HASAWA?

Posted By steven bentham I am sure you don't mean that because they are ill its okay for them to die accidently. The programme also stated that 1,000 of the deaths were preventable. Deaths in health care will include; falls, scaldings, falls from windows, blood transfer mistakes, infections - are these not preventable!! Do we not have any health care safety officers who have views?

Posted By Robert K Lewis Mark Need to be a bit careful with the word incompetent - you can make errors, be negligent but still be competent. It is not an option to be 100% error free in all our actions. I seem to remember patient treatment numbers being in excess of 20million+ per annum in the NHS which provides an error rate of potentially less than 0.1%, which is actually pretty good. The real problem in health care is that small errors have extreme consequences. I cannot think of another sector where human errors at a very minor level can have such immediate and devastating effects. Interestingly at least one paper joined this with the event at a Stockport hospital where the inquest found that most nurses could not speak english and therefore did not realise a patient could not feed himself and was starving to death in the middle of a ward in full view of all. This was to me gross negligence. Bob

Posted By steve williamson Hi Steve, Got that off your chest now? The HSE certainly does not have a hands off approach to the NHS, as I'm sure our local Principal Inspector who regularly attends our Healthcare S G meetings will confirm. Two of the 19 RIDDORS I've submitted this year concerned patients who died falling from bed and both, along with several of the others have resulted in HSE investigations. Cheers, Stevew

Posted By bigwhistle I know for a fact that one NHS trust is quite happy to potentially operate on people with what is known in the business as soiled instruments. The HSE said it was a medical issue I hope now they realise it is a safety issue.

Posted By Robert K Lewis In spite of my defence of the health service I am not employed by it and I see its faults all too clearly and some of these are clearly "management" decisions and deserve some of the strongest actions. But what I was trying to say, badly, is that there is a unique situation in patient treatment whereby there is a direct link between the individual treater and the person affected. Nuclear Station operators will be a step away from the consequence of their errors - not touching them and knowing them as individuals. It is the same with the rail industry. It is all too easy in poor lighting and times of stress to misread text less than 5 point in size. There are however the managers behind this who need to be personally confronted with their decisions. Not just when a patient dies but also whenever there is an identified breach. The fines need to hit the individuals who create the situations in their own pockets not that of an overstretched system that will only be more stretched. Unfortunately the framing of offences seems to avoid this unless the HSe perhaps start to use the employee duties of section 7 with a bit of low cunning. The approach worked in the 80s with YTS and the use of section 3 against Training Placement organisations following the maiming and death of teenagers in unsuitable employment placings. Bob

Posted By Cr8r John I feel really sorry for your sister in law. Any accident investigator worth his or her salt should find a management error as root cause if staff are put in a position where they feel compelled to make decisions or perform duties for which they are not qualified. Is this report saying that these 2000 accidents are all things like falling out of bed etc, ie not complications of the reason they were in hospital in the first place? If so, then this is amazing and equally astounding is that it doesn't appear in the RIDDOR figures each year. How is that? I do hope however that fault will not be found with the staff, who for the most part in my (limited) experiences I have found to be hardworking, conscientious and very caring. The deeper management issues are of course much more time consuming and costly to resolve. And a scapegoat is after all almost as welcome as a solution to a problem.