James Titcombe: Failing to learn and learning to fail

Last week saw the publication of yet another damning report shining a spot light on the culture of cover up and denial in our healthcare system. Bill Kirkup’s report—”The Life and Death of Elizabeth Dixon: A Catalyst for Change,” reveals a 20 year coverup following the preventable death of baby Elizabeth Dixon. Kirkup states that “…there were failures of care by every organisation that looked after [Elizabeth] none of which was admitted at the time, nor properly investigated then or later. Instead, a cover up began on the day that she died, propped up by denial and deception, which has proved extremely hard to dislodge over the years.”

Whilst these findings should be shocking, to many people with experience of how our healthcare system often responds when things go wrong, myself included—the findings of Kirkup’s report come as no surprise at all.  

Although the events occurred two decades ago, Kirkup warns that to assume the issues revealed are historic would be misguided  “…the attitudes, behaviours and systemic problems that have been exposed have not disappeared.”

Indeed, the reasons why this 20 year cover up has eventually been revealed has little to do with the current architecture of the healthcare system and everything to do with the unwavering dedication of Elizabeth’s parents who, like forensic detectives, have had to unpick conscious efforts to distort the truth and fight against a system that seemed set against helping them.

An investigation that was set up by NHS England at the request of the Care Quality Commission (CQC) in 2014 was withdrawn at the last minute, a direct order from Simon Stevens. The case was subsequently considered by PHSO but rejected for investigation in late 2015. It was only in 2017, when former Secretary of State for Health, Jeremy Hunt intervened and commissioned Kirkup to investigate, that the path of closed doors and obfuscation finally changed direction.

These circumstances beg a question that deserves a frank and honest assessment and answer; how many other similar cases are out there where serious patient safety failures have led to tragic outcomes and the response has been a similar cover up? Kirkup is clear, stating in an interview for the Independent newspaper “..it is impossible to rule out there being other people who are in a similar position. In fact, I know of some who are…”

Kirkup’s report makes 12 welcome recommendations for change. These include recommendations relating to clinical awareness and management of hypertension in children, clinical standards in private services commissioned by the NHS, communication between teams during handovers, and a review of how clinical expert witness evidence is generated.

The report also recommends training for all healthcare staff in reacting to clinical mistakes, responding with honesty and investigation and learning. 

But Kirkup’s report also includes recommendations that have been made before. The introduction of a truly independent medical examiners system, mechanisms to hold individuals to account for giving false information or covering up, and improvements in the NHS complaints system are all areas where similar recommendations have been made in previous inquiry reports. 

Failing to learn

The recent history of the NHS is interspersed with major investigations and inquiries. A quick review of the recommendations made by the Bristol report (2001), Mid Staffs (2013),  Morecambe Bay (2015) and the Gosport Inquiry (2018) reveals common themes and areas where some recommendations are repeated almost like for like. This suggests that while we have no shortage of information about what problems exist, despite the initial shock and promises that “lessons will be learned,” there are often gaps in implementation and sustained change following.

Recent events give little reason for increased optimism. Just four months ago, Baroness Cumberlege published her much anticipated Independent Medicines and Medical Devices Safety Review, looking into the response of England’s healthcare system to patients’ reports of harm from drugs and medical devices. The report found the healthcare systems to be “..disjointed, siloed, unresponsive, and defensive” and made significant recommendations for change, including the introduction of a new Patient Safety Commissioner role to champion the voice of harmed patients and families. 

However, in a session at this year’s HSJ Patient Safety Congress, Baroness Cumberlege described the government’s response to the report as “woeful” and as a consequence has set up a cross party parliamentary group specifically to push for it’s recommendations to be implemented. 

The Dixon Inquiry recommendations will now be sitting in the Department of Health and Social Care’s inbox, along with outstanding recommendations from other major inquires and the recommendations made by Baroness Cumberlege just four months ago. 

Early next month, Donna Ockenden will publish the initial report looking at the first 250 cases of potentially avoidable harm relating to maternity services at the Shrewsbury and Telford NHS Trust. While the individual circumstances relating to what happened at SaTH will be unique, it is also a certainty that the report will contain many overlapping themes with common features that have been identified before. 

What needs to happen next?

This year has seen an unprecedented challenge for the healthcare system and the government. To some extent, a pause in patient safety progress and reform has been inevitable given the global coronavirus epidemic. But moving into 2021, the government must now move forward with the patient safety agenda with a renewed sense of urgency and importance. 

Firstly, a good starting point might be to look collectively at the outstanding recommendations from both existing and soon to be published investigation reports and consolidate the common areas of recommendations into a single set of change projects with published success criteria, clear ownership, and timescales for implementation.

Secondly, it is clear that the past approach to implementation of recommendations from major inquiry reports hasn’t been fully effective and that we need a different approach. One suggestion could be for the government to set up an independent inquiry implementation committee within the DoHSC to have oversight of progress made against accepted recommendations. Such a committee could meet regularly and report progress publicly. This committee could include harmed patients and families so that those most vested in seeing meaningful change have a role in holding the system to account for implementing the changes needed to truly learn.

Unless we take a different approach to implementation of recommendations following major investigation reports, we are destined to repeat the cycle of similar problems recurring, further investigation and the same recommendations being made again and again—failing to learn and learning to fail.

Harmed patients and their families have consistently been the driver behind major healthcare inquiry reports which often happen only after the cumulation of years of arduous battles against the system at great personal cost. Nadine Dorries is right to describe this as “inhumane,” but the best way to honour those affected is not through words but by acting on the recommendations and changing the system once and for all. 

James Titcombe, Patient Safety Campaigner and co-founder of Harmed Patients Alliance.

Competing interests: None declared.