The Delayed Response to The Cumberlege Report: First Do No Harm is a Continuous Threat to Patient Safety

The Cumberlege Report made significant waves in the healthcare sector when it was first published in 2020 and painted a deeply unsettling picture of a health service that desperately needed to prioritise patient safety.

The report, which investigated the uses of Primodos, Sodium Valproate, and pelvic mesh implants, was carried out over two years by Baroness Julia Cumberlege. Both Primodos pregnancy tests and Sodium Valproate – medication typically used to treat epilepsy – were found to be extremely harmful to pregnant women. Pelvic mesh implants used to treat incontinence in women were also discovered to be a cause of chronic pain for patients.

The lack of data and incident reports surrounding medication and devices were identified as key factors in the ongoing risk to patient care. Baroness Cumberlege offered nine strategic recommendations to prevent large-scale patient safety incidents as well as 50 actions for improvement.

The report concluded with a call for the government to establish an independent task force to implement the recommendations. In an interview with The Independent in 2020, former Health Secretary, Jeremy Hunt, spoke on the urgent need to implement the recommendations laid out in the report saying:

“We must not allow this seminal report to gather dust on a shelf. Lessons must be learnt once and for all.”

Jeremy Hunt via The Independent

What progress has been made?

The 8th of July marks three years since the Cumberlege Report was originally published, and while some progress has been made, most recommendations are yet to be implemented.

The latest update on the review from the Department of Health and Social Care was published last December and only three of the nine strategic recommendations have been fully accepted. Two have been rejected and four are still in progress.

While the appointment of Dr. Henrietta Hughes as Patient Safety Commissioner is a significant step forward, there is still progress to be made to meet the other two recommendations that were accepted in full. Further engagement with patients from the Medicine and Healthcare Products Regulatory Agency is required, as well as the opening of specialist centres to treat patients who have been affected by damaging medical treatments.

A report from Daily Mail highlighted Baroness Cumberlege’s frustration with the lack of progress being made during a committee with DHSC MPs where she stated that there was a “lack of will” from the department to implement changes. She further criticized the government for the delayed response time.

Steve Barclay, Secretary of State for Health and Social Care reiterated the government’s commitment to the recommendations accepted in the department’s official update report saying:

“We know that there is still more to do to make sure that the health and care system is safe…We have listened, we have learnt, and we will continue to work to make the healthcare system safer for women.”

Steve Barclay via GOV.UK

The Use of Data to Ensure Patient Safety

Baroness Cumberlege was confident the use of data could ensure patient safety during her opening keynote at last year’s GS1 UK Healthcare Conference:

“I’m determined to ensure we use data, that we harness technology, and we improve systems to create safer, better, more informed, and more caring healthcare.”

Baroness Cumberlege via GS1

The Scan4Safety Programme which has been introduced in trusts across NHS England follows GS1 barcode standards and offers full traceability which allows every product, patient and location to be tracked at any stage of the supply chain.

While the response to Baroness Cumberlege’s report has been disappointing, the NHS is moving further towards the implementation of digital solutions to improve patient safety. The government’s 2023 mandate to the NHS calls for adoption of “the latest innovation and technology to digitally transform the NHS and help to ensure its long-term sustainability.”

The mandate also encourages staff to develop the skills and resources that will allow them to best make use of new digital tools. Tentative plans have been put in place for all NHS trusts across England to utilise barcode technology to submit high-risk medical devices to the Medical Device Outcome Registry. This will ensure that patient safety is prioritised during procedures that require such devices.

The widespread use of barcode technology across the NHS in 2024 will enhance the already positive results from the Scan4Safety scheme and promote a move towards a safer and more innovative healthcare sector.

KMsoft is a proud partner of GS1. Our approved solution, StockAssist Medical, offers a streamlined approach to managing inventory which improves efficiencies, productivity, and enhances patient safety.

Find out more about our solutions here, or get in touch to book a demo.

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