⚠️ Mistakes in NHS Care: Why They Happen & What You Can Do

🔎 Why mistakes happen

• Heavy workload: Doctors and nurses handle huge numbers of patients and results every day.

• Fragmented IT systems: GP, hospital, and lab systems don’t always link, so information can get lost.

• Human error: Fatigue, multitasking, and assumptions all increase the risk of oversight.

• Defensive culture: Trusts sometimes minimise problems to protect reputation or avoid litigation.

Most errors are not deliberate — but they can cause harm if they are not caught quickly.
Martha’s Rule was created after a young girl died when her family’s concerns were ignored — it’s designed to stop that happening again.

🛡 What safeguards are already in place?

Although mistakes still happen, the NHS has many systems to reduce risk and catch errors early:

• Critical results alerts: Labs automatically flag dangerously abnormal results so they cannot be overlooked.

• Early Warning Scores (NEWS2): Vital signs generate a score that prompts urgent review if the patient is deteriorating.

• Sepsis protocols: Hospitals have rapid-response pathways for suspected sepsis.

• Cross-checking: High-risk drugs often require two professionals to sign off.

• Incident reporting: Staff can log “near misses” to help the system learn.

• Duty of Candour: Trusts must inform patients if serious harm has been caused by an error.

• Martha’s Rule: Gives patients/families the right to request an urgent independent review if they feel concerns are being ignored.

💻 Are new IT systems making care safer?

The NHS is moving to large electronic patient record (EPR) systems such as Epic, Cerner and Lorenzo. These bring real safety gains:

Safer features

• Automatic alerts for critical blood results.

• Built-in early warning score (NEWS2) calculations to detect deterioration.

• Electronic prescribing with dose, allergy, and interaction checks.

• Shared records across hospitals, GPs, and community services.

• Digital audit trails showing who reviewed results and when.

But challenges remain

• Too many alerts can cause “alert fatigue,” leading staff to dismiss warnings.

• System crashes or downtime can force staff back to paper, which is less safe.

• Complexity can slow clinicians down until they are confident with the system.

• Hospital and GP systems still don’t fully integrate everywhere, so results can still be missed.

Bottom line: New IT has improved safety compared to the old paper-and-fax systems, but it isn’t foolproof. It works best alongside clinical vigilance and patient involvement.

✅ What you can do if you suspect a mistake

Step 1. Check directly with the clinical team

• Ask: “Can you confirm this result/issue has been reviewed?”

• Request a written explanation or clinic letter.

• Keep notes of the conversation.

Step 2. Escalate to a senior doctor/clinical lead

• Ask who the consultant in charge is.

• Write your concern clearly and factually.

Step 3. If your loved one is deteriorating: use Martha’s Rule

• You can request an urgent review by a critical care team, separate from the ward team.

• Available 24/7 in hospitals where introduced.

• Say: 👉 “We want a review under Martha’s Rule.”

• If not yet in your hospital, ask for the critical care outreach team.

Step 4. Contact PALS (Patient Advice & Liaison Service)

• They can chase answers and log concerns.

Step 5. Make a formal complaint to the Trust

• Keep it factual (what happened, why it matters, what outcome you want).

• The Trust must acknowledge within 3 working days.

Step 6. Escalate outside the Trust

• If unsatisfied, go to the Parliamentary and Health Service Ombudsman (PHSO).

🧭 Tips to protect yourself & your family

• Keep copies of all results and letters.

• Track your results in a simple log.

• Bring support (family, advocate, charity like AvMA).

• Stay factual: stick to dates, facts, and impact.

🔑 Key message

Mistakes in healthcare happen for many reasons — but the NHS has safeguards and new IT systems to reduce risk, and Martha’s Rule adds an extra urgent safety net.

Patients and families still play a vital role by asking questions, checking results, and speaking up.

You are not being difficult — you are being safe.