If we truly believe in a just culture and the benefits this can bring for patient safety, it has to give equal importance to being fair to patients and families as well as to staff.
The lexicon of a “just culture” in the NHS has become popular over recent months, notably in the publication of Being Fair: Supporting a just and learning culture for staff and patients following incidents in the NHS by NHS Resolution.
We are taught that to create this culture, when things have gone wrong, we need to focus on three questions (Dekker 2017): Who is hurt? What are their needs? And whose responsibility is it to meet those needs?
There is much to celebrate in the increased focus on “just culture”– not least that this has become accepted parlance within the NHS mainstream and more widely in the regulatory community. The phrase can be found in the National Patient Safety Strategy from NHS England/NHS Improvement.
It is advocated in the General Medical Council-commissioned review on gross negligence manslaughter and culpable homicide. There is A just culture guide, from NHS Improvement, which “encourages managers to treat staff involved in a patient safety incident in a consistent, constructive and fair way”.
Yet from the perspective of patients and families, the narrative to date can seem somewhat one sided. In our view, a “just culture” has to give equal importance to being fair to staff and patients.
In the aftermath of a patient safety event resulting in serious patient harm or death, the response of the organisation to the patient or family is crucial. Yet too often, rather than the restorative approach Dekker calls for, harmed patients and bereaved families experience a response that in many cases significantly exacerbates their grief, trauma and distress.
Given the notion of justice encompasses concepts of fairness and equity, the pursuit of a just culture must also ensure further harm to patients and families is avoided.
At recent events hosted by AvMA and The Doctors’ Association UK, harmed patients and families sat side by side with clinicians and researchers. It was moving and heartening to hear the empathy felt by both “sides” expressed for all affected by the fallout from patient safety incidents.