Article Published in the British Medical Journal by Francesca Robinson
In the wake of the Bawa-Garba case a campaign by the Doctors’ Association UK to end blame culture in the NHS has received high profile support.
“Your campaign is crucial. It will change minds. It will change approaches and lead to far greater success than outmoded ways of thinking. Your title tells the story: ‘Learn Not Blame.’” This was how, by video message, the safety expert Don Berwick endorsed a campaign that says that blaming professionals when healthcare goes wrong poisons efforts to learn from what happened. The UK government’s former patient safety adviser, Berwick is president emeritus and senior fellow of the Institute for Healthcare Improvement in Boston, Massachusetts.
The Doctors’ Association UK launched its Learn Not Blame campaign just six months ago in the wake of the Hadiza Bawa-Garba case. It calls for a change in the culture of the NHS to improve patients’ safety and healthcare professionals’ wellbeing, and it is already having an impact.
In 2015 the trainee paediatrician Bawa-Garba was found guilty of gross negligence manslaughter after a boy in her care, Jack Adcock, died. She received a suspended prison sentence (bmj.com/bawa-garba).
The Doctors’ Association UK was formed in 2018 by doctors outraged when the General Medical Council won a High Court appeal to erase Bawa-Garba from the medical register despite a ruling by a medical practitioner tribunal that she was safe to practise. She successfully appealed.
A cake iced with the phrase “Learn Not Blame” was subsequently delivered to the GMC, warning it of what was to come.
Climate of fear
The Learn Not Blame campaign wants an end to the threat of imprisonment for doctors who make mistakes, to reduce what it describes as a climate of fear in the NHS.
The campaign’s lead, Cicely Cunningham, a clinical oncology trainee in Glasgow, says that Learn Not Blame reflects the profession’s anger. She was so emotionally affected by Bawa-Garba’s case that she couldn’t sleep the night after the GMC won its appeal to erase her from the register, she told The BMJ. At 1 am she phoned a number on the website of BBC Radio 4’s Today news programme, and someone picked up. She told the bemused producer who answered that the case needed to be discussed. Coincidentally, the then health secretary for England, Jeremy Hunt, was being interviewed on the show that morning, and thanks to Cunningham’s intervention the matter was raised with him on air.
The campaign launched at an event at parliament in November 2018, attended by MPs, patients who had experienced medical harm and their families, whistleblowers, policy makers, and the current health and social care secretary for England, Matt Hancock. The next day in the House of Commons Hancock raised the issue of the need for a more compassionate culture in the NHS. He repeated these concerns a week later in a speech calling for NHS leaders to encourage whistleblowing, listening to patients, and shared learning.(1)
The campaign has attracted thousands of followers on social media, gained national media coverage—including in the Guardian,(2) the Times,(3) and The BMJ(4) and on BBC Radio(5)—and has been endorsed by healthcare leaders, including Hancock.
It has also contributed to a House of Lords meeting on harassment in the NHS, and the campaign group has joined an anti-bullying alliance that includes the Royal College of Obstetricians and Gynaecologists.
Hamilton and Williams reviews
Learn Not Blame contributed to the cardiac surgeon Leslie Hamilton’s independent review for the GMC of the use of gross negligence manslaughter and culpable homicide laws in medicine, published earlier this month(6). Full implementation of Hamilton’s recommendations, the campaign says, should mean far fewer prosecutions of healthcare workers in future.
One of the campaign’s founders, Jenny Vaughan, the lead on law and policy for the Doctors’ Association UK and a consultant neurologist, opposes criminalisation of healthcare workers for errors.(7) She says that one of the most important recommendations of the Hamilton review is that workplaces should be scrutinised by the Care Quality Commission to the same degree as the individual professional.(8) Investigations should take into account the working environment and the pressure the doctor was under, Vaughan says, and the whole system should operate more consistently.
Learn Not Blame also backs the recommendations of Norman Williams’s review last year of gross negligence manslaughter in healthcare, commissioned by the health secretary, which proposed improvements to the expert witness system.(9)
The campaign says that everyone working in the NHS should be empowered to do what they can in their own sphere of influence to ensure safer patient care and a better workplace. It is prompting conversations about how the NHS can engender accountability and swap learning for blame, Cunningham says.
To blame is human
Blaming workers is a natural response, Cunningham says, especially if people fear being blamed themselves. But evidence shows that witnessing a colleague blaming someone else can be socially contagious.(10) Such behaviour can spread through a workplace, and the campaign’s message is that people can stop that chain.
Although the campaign’s ambitions are big, Cunningham says that they can be realised through many people doing small things. For example, she has launched an initiative in her hospital for staff to report examples of excellence in healthcare to use for learning and to improve staff morale.(11)
“We want everyone working in the health service thinking about these issues and doing what they feel are the most important and appropriate things that they can do,” she says. “It’s about empowering people to have these conversations and to be an advocate for a just culture and a learning culture in their workplace.”
Such discussions may concern patients and families who have experienced avoidable tragedy, she adds. Most want to know the truth and reassurance that it will never happen again. But many have described believing that they had no choice but to pursue adversarial processes such as complaints and litigation.
Question the system
“On an individual level more of us accept that we must question the system if we perceive something is unsafe. In the past we often had to keep our heads down,” Cunningham thinks.
Vaughan, as an educational supervisor at Imperial College Healthcare Trust, thinks that since the Bawa-Garba case trainees have become more willing to raise concerns with managers about staff shortages and potentially unsafe situations. For example, her trust is considering changes to its specialist drugs prescribing system after one of Vaughan’s trainees raised concerns, citing the Bawa-Garba case.
“Bawa-Garba was working in unsafe conditions that day and was wholly blamed, along with nurse [Isabel] Amaro, when things went wrong on a busy shift. Jack Adcock should certainly have received better care, but the hospital has escaped any responsibility. Criminalising these kinds of errors is simply wrong and risks setting the patient safety agenda back by 30 years,” Vaughan says.
Hancock M. Leadership speech. Nov 2018. https://www.matt-hancock.com/news/nhs-leadership-speech.
Campbell D. Dossier reveals “petty tortures” of NHS trainee doctors denied leave. Guardian. Mar 2019.https://www.theguardian.com/society/2019/mar/28/nhs-trainee-doctors-denied-leave-dossier-hospitals.
Times letters: treating the root causes of a “dysfunctional” NHS. Times. Feb 2019.https://www.thetimes.co.uk/edition/comment/times-letters-treating-the-root-causes-of-a-dysfunctional-nhs-d0ss0n7kc.
Vaughan J. The Bawa-Garba case should usher in a fairer culture in healthcare. BMJ Opinion. May 2019.https://blogs.bmj.com/bmj/2019/05/09/jenny-vaughan-the-bawa-garba-case-should-usher-in-a-fairer-culture-in-healthcare.
Why do we love to blame someone when things go wrong? BBC. Feb 2019.https://www.bbc.co.uk/programmes/p070n3g0.
Dyer C. Medical manslaughter: independent review calls for root and branch reform of cases. BMJ2019;365:l4106.doi:10.1136/bmj.l4106 pmid:31171513
Jenny Vaughan: Overturning injustice. BMJ2019;364:l1024.pmid:30872373
Vaughan J. Medical manslaughter: will the findings of an independent review be a tipping point for change? BMJ Opinion. June 2019. https://blogs.bmj.com/bmj/2019/06/06/medical-manslaughter-will-the-findings-of-an-independent-review-be-a-tipping-point-for-change.
Department of Health and Social Care. Williams review into gross negligence manslaughter in healthcare. Jun 2018.https://assets.publishing.service.gov.uk/government/uploads/
Fast NJ, Tiedens LZ Blame contagion: the automatic transmission of self-serving attributions. J Exp Soc Psychol2010;46:97-106doi:10.1016/j.jesp.2009.10.007.
Learning from Excellence. https://learningfromexcellence.com