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 staff. Cicely Cunningham, DAUK’s Learn Not Blame lead, explores what a just culture really means, with James Titcombe and Peter Walsh.
‘When things go wrong, we crave something or someone to blame. It's an emotional response found in nearly every culture - but why is this something we all recognise?’
After a junior doctor was convicted of gross negligence manslaughter for mistakes made whilst working under intolerable pressure, a campaign for a just culture in the NHS was launched by DAUK. This campaign, Learn Not Blame, is lead by Dr Cicely Cunningham, a DAUK executive committee member. Listen to Cicely being interviewed by BBC World Service for The Why Factor in this episode about blame.
DAUK’s Learn Not Blame lead Dr Cicely Cunningham was invited to speak to clinical negligence solicitors discussing where professional accountability should start and end. This was followed by a panel discussion with the QC for the Professional Standards Authority who argued at Dr Hadiza Bawa-Garba’s appeal. Dr Cicely gave a thought provoking and powerful talk and promoted a stimulating discussion regarding a just culture in the NHS.
Dr Cicely Cunningham, DAUK’s Learn Not Blame Lead, in The Guardian: “In 2015, Dr Hadiza Bawa-Garba was convicted of gross negligence manslaughter for her part in the death of six-year-old Jack Adcock from sepsis. She was subsequently struck off the medical register after the doctors’ regulatory body, the General Medical Council, argued that the conviction meant that she could not be fit to practise. The court of appeal ruled on Monday that Bawa-Garba should be reinstated. I believe it was the right decision.”
The message from the GMC at Dr Bawa-Garba’s appeal was clear; that systemic failures should not have been taken into account when determining whether an otherwise excellent doctor should be struck off. We now find ourselves in the unprecedented situation where doctors feel that on any given day in the NHS, that they too could be criminally convicted and pursued by their regulator in the courts to ensure that they will never practice medicine again. The GMC has shown it cannot be trusted to take a balanced and non-punitive approach in the context of system failures.
‘The GMC’s aggressive pursuit of an otherwise highly regarded doctor, against the advice of the Medical Practitioners Tribunal Service (MPTS), that has prompted widespread outrage amongst doctors. This serious error of judgement on the part of Mr Charlie Massey, which was also criticised by the Professional Standards Authority, has led to an unprecedented loss of confidence in the regulator by the medical profession.’