The impact of reorganising NHS services on patient safety

This blog post was published by the Healthcare Safety Investigation Branch (HSIB). Find out more about HSIB legacy.

Scott Hislop, Deputy Director of Investigations.

We know that NHS organisations may sometimes need to reorganise their services to consider how they can best deliver care to patients.

This can mean there is a need to repurpose existing environments, for example hospital wards or clinical areas. Staff may also be redeployed to deal with surges in demand when the pressure on the system is at its greatest. We commonly see this during winter, with ‘winter pressures’ wards, but we have also seen this become more common during other times of the year as the NHS deals with the lasting impact of coronavirus (COVID-19) and staff shortages in some key areas.

It’s important that the NHS has this ability to adapt to try and make sure it can deliver the best and safest care to as many patients as possible. The ability to flex in this way helps to keep the NHS operating when it is at its busiest and makes sure that patients can still access appropriate care.

Examples from HSIB investigations

Through our national investigations at HSIB we have seen a number of examples of where these adaptations have gone well, but we have also seen situations where adaptations may have had unintended impacts on patient safety.

In recent investigations, HSIB has seen the following issues associated with repurposing or redeployment.

Management of sickle cell crisis

In this investigation, a patient attended hospital in sickle cell crisis, but experienced morphine toxicity and died.

Due to COVID-19 pressures, the ward where patients with sickle cell disease were cared for prior to COVID-19 had been repurposed to an acute medical ward. Because of this, a patient in sickle cell crisis was transferred to a different ward where no one was trained to set up the prescribed patient-controlled analgesia (PCA) pump. The patient was then transferred to a further ward where the PCA pump was set up, but the staff were not trained in the monitoring requirements necessary when a patient is receiving medicine via a PCA.

Access to critical patient information at the bedside

A patient was misidentified meaning an opportunity to provide resuscitation was missed.

The hospital ward had recently been repurposed from a day-surgery environment to a care of the older person ward due to COVID-19. This meant some usual ways of working for medical staff were not possible. Nursing staff had been redeployed to the ward from across the hospital in support but were not familiar with caring for medical patients.

Medicine omissions in learning disability secure units

A patient was not provided with physical health medication that had been prescribed for his diabetes and high cholesterol.

Due to staff shortages, mental health nurses were used to fill learning disability nurse vacancies. However, the investigation found this impacted on patient care as (without appropriate support and training) mental health nurses may not have the relevant communication methods and strategies to assist patients with learning disabilities to take their medication.

Read the report: Medicine omissions in learning disability secure units.

The design of the paediatric ward

A patient was admitted to a general paediatric ward after attending hospital with suicidal thoughts. They absconded and took an overdose of paracetamol.

Paediatric wards in acute hospitals are increasingly caring for children and young people who have mental health needs. Paediatric wards are primarily designed to accommodate children with physical health needs and are not specifically designed to help keep children and young people with mental health needs safe.

Oxygen issues during the COVID-19 pandemic

A major incident was declared when an NHS Trust needed to divert patients to other hospitals because of increased demand on its oxygen supply. The Trust had made plans to create additional bed spaces for COVID-19 patients but had not been able to fully consider the impact these plans could have on oxygen flow to other areas in the hospital.

Read the report: Oxygen issues during the COVID-19 pandemic.

Mitigating the risks

NHS organisations face challenging decisions when they need to repurpose environments and redeploy staff. In each instance, these decisions may help to mitigate one hazard, while creating others. We must acknowledge this when considering how NHS organisations promote and maintain patient safety, as they often have to choose between resources and which hazard seems the most pressing or greatest concern.

We have seen that negative impacts of repurposing or redeployment seem to happen more often where there is limited ability or capacity to proactively plan for adaptations. This can mean that organisations take a ‘one size fits all’ approach to adaptations, where the specific characteristics of the environment or specific skills and competencies of staff may not be considered.

However, there are positive measures that NHS organisations can take to try and make sure they fully understand the hazards they are addressing, and those unintended consequences or hazards that may spring up as a result of repurposing or redeployment decisions.

For example, try to:

Create capacity to proactively plan for repurposing and redeployment decisions.
Ensure a full range of professions and specialisms are included (clinical and non-clinical) that can consider the different impacts repurposing or deployment may have on patient care.
Consider what specific environmental adaptations may be needed to support specialist patient care in a new environment.
Consider what additional equipment and technology may be needed to provide care in repurposed environments.
Consider what additional training, competencies or support staff may need to provide care to groups of patients they may not routinely care for.

It may not always be possible to fully mitigate risks resulting from these decisions. However, a proactive consideration by NHS organisations can help to ensure that hazards and risks can be identified, discussed, and decisions taken with the best available insight and knowledge about what the impact on patient care may be.

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