There was relief for some families earlier this month when the CQC published its report on NHS investigations into unexpected patient deaths. It concluded that investigations were poorly handled with too few lessons being learnt on how to prevent future deaths. The report also noted that bereaved families were essentially side lined with little or no information about their rights, or available support, when a relative dies.
Haven’t we heard this before?
One of the most damning statements in the report was: ‘Many carers and families do not find the NHS to be open and transparent’. Since the Mid-Staffs scandal, there have been numerous initiatives to improve openness between patients, their families and hospital staff including ‘Sign up to Safety’, the introduction of a Duty of Candour, and Robert Francis’ report into NHS reporting culture, among others. But how much has the NHS really learnt? And how many more initiatives can it take on board given the significant funding constraints and pressures it is currently facing?
More initiatives to prevent unnecessary death and injury
The prevention of unnecessary deaths is a familiar theme. In October this year, Jeremy Hunt announced another initiative, a consultation on a new ‘rapid resolution and redress’ scheme (basically a voluntary compensation scheme) for victims of maternal care negligence. This came on the back of a report, published in March, titled ‘Spotlight on Maternity’ in which Trusts were charged with the task of improving maternity outcomes (a Lancet report into numbers of stillbirths ranked the UK 24th out of 49 high income countries). In November 2015, Jeremy Hunt stated the government's ambition to halve all birth-related deaths and brain injuries by 20% by 2020 and 50% by 2030 - on the basis that if an organisation, at a local level, decides to focus on one particular area, then the outcomes will be greatly improved.
Learning from mistakes without fear of retribution
Understandably, any scheme (such as the one being proposed) to help reduce medical negligence claims is to be welcomed on the basis that prevention is better than cure. The proposals include the establishment of a ‘safe space’ where medical practitioners can ‘speak freely’ enabling them to ‘learn from their mistakes’ without fear of public disclosure or blame. This links back to the CQC finding that transparency is in short supply in the NHS but does little to address some of the fundamental problems faced by NHS Trusts, namely inadequate leadership, insufficient staffing and training levels, and cultural protectionism.
Small, incremental changes
The Sign up to Safety campaign acknowledges that progress has not been as good as hoped, or as sustained. Its desire to create ‘a joyful, trusting, open and optimistic approach to patient safety’ sounds increasingly like wishful thinking. However, it does emphasise that locally-led initiatives are most likely to succeed: concentrating on making small, incremental changes at Trust level will be more effective in the long run than trying to change an entire organisation. Thus, improving the way investigations into unexplained deaths are conducted and changing the way maternity services are delivered at hospital level, must be the way to go – providing the leadership is able and willing to drive through the changes.
Patient safety compromised by recruitment difficulties
The changes in the way Basildon Hospital was run, instigated by the (newly appointed) chief executive who put ‘compassion, care, openness, transparency and learning’ at the centre of their operations, ensured that it came out of special measures. Having the right leader in place, willing and able to implement recommendations for improving patient safety, internal culture and dealings with patients’ families is something all hospitals can, and should, aspire to. Funding is always going to be an issue but an innovative, open-minded approach to improvement can go a long way.