At a Global Patient Safety Summit earlier this month, it was announced that for the first time health trusts in England have been ranked on their ability to learn from mistakes, in what is set to be an annual occurrence. The measure comes against a backdrop of Health Secretary Jeremy Hunt recognising that ‘every week there are potentially 150 avoidable deaths due to medical negligence in our hospitals’.
Trusts have been scored on the fairness and effectiveness of their procedures for reporting errors; near misses and incidents; staff confidence and security in reporting unsafe clinical practice; and the percentage of staff who feel able to contribute towards improvements at their trust. Out of a total of 230 trusts, 18 were ranked outstanding and 102 good, whilst 78 gave ‘cause for significant concern’ and 32 had a ‘poor reporting culture’.
However, it can be hard to feel a sense of confidence in the integrity of the ranking system. Notably, the best placed trust – Northumbria Healthcare NHS Foundation Trust – has in the past been widely reported to have relied on compromise or settlement agreements to prohibit leaving employees from disclosing information about the Trust, and in many cases, even the existence of the agreement.
Mr Hunt talks of a ‘new era of openness’ in the NHS, calling for a move in culture ‘from blaming to learning’. He identifies a need to ‘acknowledge that sometimes bad mistakes can be made by good people’ and to make ‘whistleblowing and secrecy a thing of the past’. With these aims in mind, Mr Hunt has revealed a series of further plans including:
- The formation of an independent Healthcare Safety Investigation Branch. NHS staff will be able to report concerns to the Branch without their name being attributed to the report, thereby avoiding potential conflict with their employer.
- Affording NHS staff who report or give information during investigations about mistakes with legal protection.
- Giving honest NHS staff who admit mistakes and apologise credit at professional tribunals.
- From April 2018, all deaths which occur in hospitals being independently reviewed by expert medical examiners who will confirm the cause.
In an article for the Independent newspaper, Mr Hunt wrote that he had ‘met too many patients and families who have faced a closed and defensive culture when they’ve tried to find out the truth about things that go wrong’. This is all too often the experience of our clients. In many cases it is this secretive and defensive approach following the reporting of a mistake – and the consequent missed opportunity to learn lessons – which our clients find the most distressing. The protracted and difficult process of fighting for answers and apologies can feel more challenging than coping with the injuries and losses that the mistake has caused.
Whilst many have welcomed the new initiatives, there remain serious concerns about fundamental flaws in the process by which mistakes in the NHS are investigated – flaws which the new initiatives do not address. The Chief Executive of Action Against Medical Accidents (AvMA), a patient safety and justice charity, has warned that the new measures will not combat the ‘woeful inconsistency and often inadequate quality of NHS investigations into serious incidents overall’. Indeed, Peter Walsh emphasises that ‘we desperately need to see serious improvement in the capacity of NHS investigations to get to the bottom of patient safety incidents and bring about real improvements in patient safety’.
It remains to be seen whether these measures will bring about their intended effect and ensure that families get the ‘full truth faster’ which Mr Hunt speaks of. However, the success of measures taken in the past to increase openness, transparency and candour within the NHS has been called into question. For example, it has previously been reported that not one person has yet been found a comparable job by a re-employment scheme set up for sacked NHS whistleblowers in the wake of Sir Robert Francis’ report into the Mid Staffordshire scandal.
The impact of the changes will be something to keep a close eye on going forwards. After all, with an increasingly overloaded NHS, rife with chronic understaffing, underfunding and under-resourcing, there unfortunately will be potentially plenty of opportunity for mistakes to be made which present a chance for learning.