“The fear culture is driving the good out of healthcare – yes malicious acts should be punished – but honest mistakes and inadvertent errors are different. And they should be understood to be different and they should be mapped by different responses so that we can learn improve and stop them happening again.”
Scott Morrish – campaigner and bereaved parent
The Doctors’ Association UK officially launched its Learn Not Blame campaign in Parliament on 20th November 2018, attended by the Secretary of State for Health and Social Care, Rt. Hon. Matt Hancock MP. With the support of Dr. Philippa Whitford MP who chaired the meeting, speakers included Professor Edwin Jesudason, Mr. Scott Morrish, Mr. Nick Ross, and Dr. Cicely Cunningham.
There was a shared appreciation amongst those present in the room for the NHS, its successes and the good it has achieved. However the stories related by speakers and those in the audience highlighted the need to face its darker side, one that has exacted a toll in human suffering, and led to catastrophic consequences for some of those working within and receiving treatment from it.
Central to the concerns expressed by those regardless of background, was the the pressing need for a change in attitude of the organisation as a whole towards its staff and patients, especially when confronted with failure. A change in culture from one of fear, defensiveness, murky secrecy and rampant scapegoating of individuals, to one that openly embraces change, and encourages those within it to strive for their best, and speak up when things are going wrong; in short – a change from a ‘culture of blame’ to a just culture.
Dr. Whitford set the scene for the launch event and highlighted key points to frame the discussion to follow, namely:
The core driving force behind this campaign is a desire to advocate for and to promote patient safety.
Patient safety is currently being compromised by a culture that stifles the willingness of staff to speak up about problems they face and situations that endanger patient safety.
This same culture punishes (often with extreme prejudice) whistleblowers who raise awareness about problems that affect patient safety.
As a result, progress and improvement is hindered as mistakes cannot be learned from.
In a moving testimony, campaigner Mr. Morrish related the story of his son Sam, who at age 3 passed away from sepsis avoidably. The trauma of their family’s experience was compounded and significantly extended as they encountered roadblock after roadblock in their search to find answers, and were lied to regarding the nature of Sam’s condition and how preventable it was.
“Sam’s death taught me that NHS was not as safe as it could be. That when NHS competence was threatened, its failure to truly understand Sam’s death or truly fulfill its duty of care to us or the staff that tried to save Sam, demonstrates failures of leadership and governance – first locally and then nationally.
“There was a conspicuous absence of checks and balances against their misuse of hierarchical power. Accountability in the NHS was defective. Respect compassion and care should be at the core of how patients and staff are treated. Not only because that is the right thing to do, but because patient safety outcomes experiences all improve when staff are supported, valued and empowered.”
Mr. Scott Morrish
Whilst we may assume that this is a one off occurrence, Mr. Morrish warned against such thinking, noting that often those investigating them begin to notice a ‘pattern of one offs, that eventually become known by their location, eg. Mid Staffs’. To prevent this happening again and again, the entire culture of the NHS must be changed, to one where staff are empowered and unrestricted learning and improvement in order to improve patient safety and outcomes is the core ideal.
“We must turn away from the fear culture, the US and THEM culture,
The blame and shame culture,
The super gag to save your skin and ‘to hell with everyone else’ culture,
The formulaic letter of apology to tick a box compliance culture,
That like clockwork receives threadbare assurances of lessons learned so that everyone can get back to the ‘real work’; which in the absence of learning and improvement is still shaped by the ‘them and us’, ‘blame and bullying and fear’ and the tragic inevitability of yet more avoidable harm.
Cultures of fear are dangerous.”
Mr. Scott Morrish
Broadcaster and TV presenter Nick Ross took the floor next, and related his own family’s experiences of having been failed by the NHS. Having been subject to the seemingly impenetrable bureaucracy surrounding the ‘botched birth’ and ‘botched operation’ affecting his children, the circumstances of which were never clearly explained to him at the time, Ross explained the ‘deeply human’ feelings of anger and outrage at how they were treated.
The audience and indeed the NHS should be thankful that Ross has accumulated extensive knowledge through his own career of investigating the historical effectiveness of crime prevention strategies, and applied such evidence based conclusions to medical negligence and the phenomenon of medical error. He quite succinctly summarised that despite the natural human inclination towards regarding punishment as ‘just’ and ‘necessary’ to prevent crime (as illustrated across the course of human history), the study of crime illustrates that methods including increasing incarceration rates, did little to prevent the rise in crime, and that crime actually fell during periods when tariffs went unchanged. This formed the premise for a key point as follows;
“There is no evidence to suggest that being punitive to people works in the way we might assume it does , and no correlation between being punitive and success. So, when there is no evidence to suggest it works on people trying to do harm, how on earth can it work on people trying to do the right thing?”
He then highlighted that using punishment in the form of gross negligence manslaughter legislation when dealing with honest, unintended medical error made by medical and nursing professionals has led to demonstrably propagating an atmosphere of fear in which the disclosure of mistakes and error in the spirit of learning has been significantly hindered. In a heartfelt plea, he alluded to the warping of the term ‘justice’ in the context of such punishment, and how enacting it as described, provided neither closure nor peace.
“The current situation isn’t blame free, it is full of blame.
It is ‘Blame rather than Learn’. ”
Professor Edwin Jesudason
Speaking up about unsafe environments for patients and staff in the NHS when normal channels do not effectively deal with the concerns is a duty incumbent upon all medical professionals. However, it is a dangerous endeavour, as encountered by Professor Edwin Jesudason, an accomplished paediatric surgeon working at Alder Hey hospital in Liverpool.
Professor Jesudason explained how blowing the whistle on unsafe care of patients at his hospital resulted in a concerted effort to suppress the information he brought forward and discredit his reputation. His talk; ‘Profound Questions about Public Authorities, raised key points about the way that medical error is often dealt with, some of which are outlined below:
“The law often acts against the public interest when it comes to patient safety. In fact the adversarial system tends to protect institutional interests, promotes blame of people who speak up and pay them off, and stifles investigation and learning.”
When settlements are reached with trusts regarding cases of avoidable patient harm either with patient’s families or staff members, many reports and the conclusions of investigations conducted into why such events took place and importantly how to prevent them in the future, are lost to the public eye forever.
Thus any learning from such events is impossible.
Hospital trusts are free to then respond to inquiries from bereaved parents stating that investigations have been conducted and care has been improved, whereas in actual fact patient care is impeded as a result of the pay offs and settlements.
“ Allegations of patient harm go beyond the cases mentioned in this document
We can expect more damaging revelations. There are only two possible outcomes;
1) Major department restructuring with Jesudason returning in triumph to a position of unfettered leadership
2) A very dirty fight, in the public eye, with the sole aim of trying to damage the reputation of Dr. Jesudason and bring him before the GMC for sanction.’
Internal letter as related from Alder Hey Hospital responding to Professor Jesudason’s case.
Jesudason’s final point is worth bearing in mind, essentially that ‘learning cannot take place in the absence of vital information and reports that is often quashed by settlements that are intended to shut down coverage and attention on the adverse event’.
“We too are human and have made our own mistakes – as individuals and as teams – or as a cog in a system that has failed. Each one of us has our own stories that haunt us, where things have gone badly.”
Dr. Cicely Cunningham.
Dr. Cunningham spoke passionately about the Learn Not Blame campaign and its ethos.
Picking up on the points made by previous speakers, she reiterated the all pervading fear of blame that permeates the working culture we all operate in;
Focusing blame on individuals rather putting the spotlight on how the organisation could learn from what had occurred.
The threat of referral to the General Medical Council; proportionately more likely to be faced by black and minority ethnic (BAME) doctors.
The prospect of facing criminal proceedings for genuine errors – vanishingly rare but seemingly arbitrary.
That learning and progress requires a willingness to change and that in turn is only possible in an atmosphere of openness and honesty, values which are totally opposed to the blame culture, and impossible within it
“We need culture change full stop.
We need a culture that reflects the values of the NHS, one that is caring, and values people, whether you are patient or a staff member. This is not ‘soft and fluffy’, it is hard and it is impactful.”
Dr. Cicely Cunningham.
KEY POINTS FROM THE FOLLOWING Q&A:
We were lucky to have some invaluable contributions from the assembled audience. Dr. Josephine Ocloo, PhD in patient safety related her own harrowing account of having to navigate the tortuous NHS complaints system following the avoidable death of her daughter, a task made more difficult by what she felt was the increasing corporatisation of NHS trusts. This point was picked up on by Dr. Whitford, noting that it appeared that their primary motivation was profit with unblemished reputation at the expense of patient safety. Rosie Cooper MP pointed out the difficulty in determining ultimate responsibility for decisions, a trend so entrenched in the NHS due to services being commissioned, audited and regulated by a plethora of different bodies.
“We have to change this appalling culture in which if someone speaks up they are crushed…there is nothing to be gained by crushing someone.”
Norman Lamb MP
Dr. Claudia Paoloni, President-elect of the HCSA, related her experiences of the incident reporting systems that exist at present. She felt that the often disappointing reality of encountering management jargon in lieu of effective action in response to concerns spoke of a culture that stemmed from the corporate ideal, relegating patient safety to a lower priority.
Accountability and responsibility used interchangeably – they are not the same thing…
If an individual feels the need to blow the whistle, the organisation has failed them.”
Dr. Clare Holt, former Air Traffic Controller, Associate at Warwick Business school
SECRETARY OF STATE FOR HEALTH AND SOCIAL CARE Rt. Hon. MATT HANCOCK MP:
Secretary of State for Health and Social Care Rt. Hon. Matt Hancock MP attended the meeting for the last half hour, and it is worth noting that the launch overran as he was keen to continue the discussion. In his opening words, he expressed his strong desire to see a culture change in the NHS, highlighting the detrimental treatment of whistleblowers historically and the need for a culture that is honest about errors, learns from them and accepts they will occur.
“…the error is where there is failure to learn. Failure is when the error is covered up. We need culture change led from the top; leadership at all levels. All the way up to the chief executive.”
Secretary of State for Health and Social Care, Rt. Hon. Matt Hancock MP.
In the following Q&A with audience and panel members; Mr. Hancock agreed that whistle-blowing was ‘the tip of the iceberg’ and that it should not be the standard safety measure. When pushed by Nick Ross, Mr. Hancock stated he was ‘open to the idea’ of changing the law to stop doctors being imprisoned under Gross Negligence Manslaughter legislation .
Mr Morrish articulately and eloquently outlined three key themes for any future change to address, namely, rethinking regulation, the need to build a just culture collaboratively and the need for the NHS to accept moral responsibility for the harm done to this point.
It is very encouraging that the Secretary of State has referenced ‘Learn Not Blame’ in a speech to the House of Commons within 24 hrs of the launch. This is the beginning of the fight for a just culture in the NHS. There is much progress to be made, and change has to come from the grassroots as much as it has to from the top.
We hope you will support us.
The video of the entire event can be viewed below.
Dr. Neil Tiwari