NHS Resolution’s analysis of data for the first year of its indemnity scheme for general practice has identified that quicker and more accurate diagnosis and improved prescribing processes could result in better patient outcomes.

The report provides a comprehensive review of the Clinical Negligence Scheme for General Practice (CNSGP) from its inception on 1 April 2019 to 31 March 2020. The review covers 401 reported cases, of which 81 were formal claims (letter of claim or court proceedings). It is somewhat unique in evaluating both open and closed cases, including potential claims such as patient safety incidents and complaints responses amounting to an admission of breach of duty.

Initial findings on claims frequency

By patient condition

• Cancer: 9.3% (of total)
• Cardiac: 7.3%
• Sepsis: 5.3%

By cause

• Delay / failure to diagnose: 43.5%
• Medication error: 18.5%
• Delay / failure to refer: 10%

There is an overlap between delay / failure to diagnose and failure to refer.

Themes

The first four themes are an overview of the most common clinical cases; the other two being stand-alone topics.

1. Cancer – 37 notifications. Bowel (18%) and breast cancer (16%) were the most frequent. The other 24 comprised small numbers of various cancers. Delay / failure to diagnose and / or failure/ delay to refer accounted for 78.4% of all cancer cases.
2. Cardiac – 29 notifications. The most frequent of eight categories were myocardial infarction (38%) and cardiac arrest (28%). Delay / failure to diagnose accounted for 38% of all cardiac cases and failure of follow-up arrangements 24%.
3. Sepsis – 21 notifications. The most frequent categories were undefined (19%), urological (19%) and respiratory sepsis (14%). Delay / failure to diagnose featured in 81% of all sepsis cases.
4. Other orthopaedic injury / infection – 17 notifications. This category includes any injury to the musculo-skeletal system, excluding orthopaedic fractures. Of ten categories, upper limb/ digit injury/ infection was the most common (23%). Delay/failure to refer was the cause in 35.3% and delay/ failure to diagnose in 29.4% of all cases in this category.
5. Medication errors – 74 notifications. Medication errors are relatively common but preventable. Failure to prescribe/ dispense was the most frequent category (23%), followed by adverse reaction (20.3%). Immunisation/vaccine error, incorrect medications and medication dose error each had 12.2% of cases.
6. Prison healthcare – 34 notifications. The proportion of cases received does not suggest a particular problem and the data is insufficient to draw any conclusions at present. Medication errors featured in 41% of cases. Failure /delay in prescribing/ dispensing was the most frequent cause (29.4%).

Recommendations

Eight recommendations are made spanning three issues:

Delay/ failure in diagnosis

• Exploration of the feasibility of a patient acuity risk assessment tool to assist in earlier identification of deteriorating patients.
• Continued promotion of existing safety netting tools.
• Exploration of the feasibility of further development of the advice and guidance service between primary and secondary care.
• Introduction of Protected Learning Time across general practice teams.

Medication errors

• Professional regulators to consider using the Royal Pharmaceutical Society competency framework in conjunction with NICE guidance on medications management, to review prescribers and prescribing.
• Research into why clinicians override adverse drug reaction system prompts and how this might be minimised.
• Appointment of a Designated Medication Safety Office to support clinicians in each Integrated Care System.

Prison healthcare

• Consideration of increasing the use of telemedicine across the prison estate to support primary and secondary care appointments and to improve continuity of care with community services.

What to take away from the report

NHS Resolution describe the report as a “preliminary exploration” of the first year of the CNSGP scheme. Data for subsequent years may show a different pattern, not least because of the pandemic’s impact. There may be longer delays for referral or treatment, but greater accessibility through the use of remote consultations.

The report’s themes demonstrate that clinical error is often a system error, whether this is based on prescribing, diagnosis, referral, follow-up or consultation and collaboration with secondary care. The report warrants close consideration by any primary care clinician or manager tasked with auditing a practice’s systems for managing clinical risk in an ever more challenging primary care environment. It is also likely to prove useful to the wider health service, as the challenges identified are not unique to general practice.

How Capsticks can help

Capsticks is a go-to advisor for those working in general practice and their indemnifiers on claims and inquests. When working with you, we ensure not only the right result but that NHS staff understand why and feel supported. In addition we offer a range of business services for primary care.

For further information on the issues discussed in this insight please contact Majid Hassan, Cheryl Blundell, Catherine Bennett or Lucy Erskine.