On 9 May 2018 I was invited to an event at the King’s Fund to share some reflections on the recent case involving Hadiza Bawa-Garba. I started my talk with a reminder that, first and foremost, at the centre of the case is the tragic death of a young boy called Jack Adcock. Had Jack been given safe care, the outcome may have been different.
In circumstances such as these, everything must be done to learn from what has happened. Most would agree that if reckless or wrongful acts contributed to Jack’s death, then the people involved should be held to account. There is a problem however—and a major reason this case caused so much debate—when the systems and processes upon which such judgments are based cannot be trusted.
In 2008, my life was turned upside down when my wife and I lost our 9 day old son, Joshua, following serious failures in his care at Furness General Hospital, part of the Morecambe Bay NHS Trust. We faced a battle to establish the truth about what happened. There was a huge number of sometimes conflicting processes and reviews, eventually culminating in the publication of the Morecambe Bay Investigation Report in March 2015. The chair of the inquiry, Bill Kirkup said: “All healthcare—everywhere—includes the possibility of error. The great majority of NHS staff know this and work hard to avoid it. They should not be blamed or criticised when errors occur despite their efforts. But in return, all of us who work for the NHS owe the public a duty to be open and honest when things go wrong, most of all to those affected, and to learn from what has happened. This is the contract that was broken in Morecambe Bay.”
The report pointed to a range of issues. Leadership, clinical governance, and the pursuit of strategic objectives while losing sight of patient care were all factors. Perhaps most fundamentally, however, the report highlighted a culture of fear and blame.
One of the clearest lessons from past scandals such as Mid-Staffs and Morecambe Bay is that fear and safety are not conditions that can exist side by side; we must choose between them.
In 2016, the advisory group established to help set up the new Healthcare Safety Investigation Branch described the importance of a system wide “just culture.” It called for a “shared set of values in which healthcare professionals trust the process of safety investigation; and are assured that any actions, omissions, or decisions that reflect the conduct of a reasonable person under the same circumstances will not be subject to inappropriate or punitive sanctions.”
If we are to create a culture that prioritises safety over fear, it’s essential that this shared set of values is embedded in every part of the healthcare system.
A good place to start might be a charter that clearly sets out values and commitments for the treatment of healthcare staff involved in adverse patient safety events. Healthcare organisations and professional regulators including the General Medical Council and the Nursing and Midwifery Council could sign up to the charter, which could include the following key aspects:
1) A clear commitment relating to how healthcare staff will be supported in the aftermath of an adverse event
2) A commitment to treat staff fairly, with assurances that honest human error will not result in punitive sanctions or consequences
3) A commitment to ensure that adverse events are investigated by people with suitable training and the required expertise to ensure relevant system, human, environmental, and cultural factors are properly considered
4) A commitment to be transparent and share the outcomes of investigations, demonstrating the learning and changes made and the fair treatment of staff involved
5) Clear processes for identifying and escalating rare examples where the actions of healthcare professionals fall outside acceptable boundaries, ensuring such processes are transparent and trusted, and making it clear that dishonestly will not be tolerated.
The vast majority of healthcare professionals go to work each day to do the best they can for their patients. Rarely do adverse events have a single or “root” cause and, more often than not, blaming or removing an individual does little to improve safety. Instead, it simply sets up the next person to fail in the same system.
There will always be boundaries outside of which the actions of individuals are truly reckless and unacceptable, but if the NHS is going to prioritise safety over fear, we must ensure that the processes around which such judgments are made are consistent, transparent, and, above all, trusted.
Before Joshua’s death I worked as a project manager in the nuclear industry. During my career there were several times when I was involved in incident investigations. I can say with absolute honestly that, during these investigations, I was never concerned that I might be subject to unfair treatment or blame and I always welcomed the fact that such processes were taking place, as they were opportunities to learn.
We owe it to Jack and Joshua to ensure the same culture can prevail in healthcare.
James Titcombe is a patient safety campaigner and works for Patient Safety Learning. He has previously worked with the Care Quality Commission as their national adviser on safety, and recently advised on the establishment of the new Healthcare Safety Investigation Branch.
Competing interests: None declared.