Why the NHS' Recall Framework is vital to improving patient safety

It is now almost two years since NHS England published the National Quality Board Recall Framework. 

The purpose of the framework is to provide guidance to NHS Trusts on arranging a recall of patients who need further consultation, review and/or clinical management because a potential or actual problem has been identified. 

The recall framework was published following the Paterson Inquiry which found that Ian Paterson’s patients had an inadequate experience of the recall processes organised by their healthcare providers. The inquiry found the process wasn't patient-focused and lacked transparency.

What does the patient safety guidance say?

The government’s own guidance states that where there is a patient safety incident, the patients affected should be recalled to:

• ensure they are at no further harm
• resolve any harm they may still be at risk of
• determine any longer-term care they may require

If patients have been harmed, then they must receive timely treatment to rectify, if possible, the harm that has occurred. 

Duty of Candour

The Duty of Candour compels healthcare providers to be open with patients when things go wrong. Patients should be told if an error has resulted in them experiencing harm. 

Once the recall process has been concluded, there must be a focus on identifying learning that can inform clinical practice and improvement. There is no point conducting a recall if lessons are not learnt to prevent the issues from arising again. 

The framework identifies that patient safety should be the main priority. 

NHS Trusts are encouraged to work collaboratively with other organisations if, for example, a private healthcare provider has already initiated a recall of their own patients to ensure that the agreed inclusion and exclusion criteria of the recall should align as much as possible. 

It's also important in the context that there may be a group of patients who have received both NHS and private healthcare. 

Currently, more than six million people in England and Wales alone are waiting for an NHS operation, so they may opt for private treatment to reduce their waiting times. 

Supporting patients affected by harm

As a group actions medical negligence solicitor I often support patients who have been reassessed by another surgeon or specialist as part of a recall where harm has been identified. 

We're continuing to support a number of patients who had orthopaedic surgery performed by Mian Munawar Shah, formerly a consultant orthopaedic surgeon at Walsall Healthcare NHS Trust. A total of 600 patients who underwent shoulder surgery by Mr Shah have been recalled by Walsall Manor Hospital.

I also represent patients who were treated by John Williamson, formerly a consultant spinal surgeon in Manchester. 

The NHS Trusts involved have so far resisted performing a recall of his patients, despite Northern Care Alliance NHS Foundation Trust publishing its Spinal Patient Safety Look Back Review in July 2023 and Manchester University NHS Foundation Trust publishing its own report in February 2024.Northern Care Alliance’s report found several issues including: 

• Substandard surgery was performed due to lack of care and attention.
• Patients suffered long-term pain and mobility issues.
• Those operated on suffered higher than expected blood loss.
• There was a lack of informed consent by patients before operations were carried out. 
• “In a high number of cases” the risks documented on the consent form and documents didn’t reflect those of the proposed surgery.
• Mr Williamson displayed “unacceptable and unprofessional behaviour”.
• "Serious and frequently occurring significant professional issues.”

In the private sector, Spire Manchester Hospital has already implemented a recall of Mr Williamson’s patients which began in March 2023. 

I continue to seek a full recall of Mr Williamson’s NHS patients who received treatment at Manchester Children’s Hospital and Salford Royal Infirmary for a review of their care. The framework identifies that patient safety should be the main priority and if that is accurate, the only sensible outcome is that Mr Williamson’s patients should be recalled.

Find out more about Irwin Mitchell's expertise in supporting patients and families affected by care failings at our dedicated medical negligence section. 

More on NHS England's recall framework can be found online.