Director of Strategy
An “insidious negative culture involving a tolerance of poor standards”. These are the words of Sir Robert Francis ten years ago as he described failings at the Mid-Staffordshire NHS Foundation Trust. His landmark inquiry revealed hundreds of patients at the Trust had died due to poor care.
Much work has been done to improve patient safety since then and important progress has been made in some areas of clinical practice. But how far have the fundamental cultural issues identified by Sir Robert Francis really been addressed across the NHS as a whole?
In PHSO’s latest report, Broken trust: making patient safety more than just a promise, we found that there is still much further to go.
We looked at 400 investigations into complaints about patient harm, including 22 where someone had died due to avoidable failings in their care. These failings included:
-
a 27-hour delay in giving a patient life-saving medication
-
a failure to monitor seriously ill patients and escalate their care to more senior clinicians when necessary.
Far too often, these clinical failings were made worse by the way that families were treated by NHS organisations after they lost a loved one.
Defensiveness and denial
Sadly, despite more than a decade of work across the NHS to instil a culture of learning and accountability, some NHS organisations remain blighted by a culture of defensiveness and denial. Many of the bereaved families who brought complaints to PHSO were kept in the dark about what had happened to their loved one.
Even where NHS organisations did look into what had happened, we found that many investigations were not thorough. Sometimes, a patient’s death was blamed on unrelated health problems rather than what were clearly mistakes in their care. We saw evidence of NHS organisations failing to learn from their mistakes, running the risk of making the same errors again.
“A long, dragging sequence of events”
In one case, a woman described the “ordeal” of trying to get honest answers from the NHS trust that cared for her mother as a “long, dragging sequence of events” lasting more than two years.
The complex web of organisations in the NHS doesn’t help. It can be very hard for bereaved families to know where to turn without the support of independent advocates to help navigate the process.
Impact on NHS staff
When NHS organisations suffer from a defensive culture it affects staff as well as patients and families. NHS staff are working in hugely challenging circumstances as the pressure on NHS services grows. Latest figures from the GMC show that their own health is suffering, with burnout increasing and levels of satisfaction plummeting.
There are more than 1.5 million patient interactions every day and staff are often under-resourced and under pressure. It is likely that mistakes will sometimes be made. But blaming individual clinicians for unintentional errors that result from unsafe systems and inadequate processes will not lead to safer care.
Putting patient safety on the priority list
To truly learn from failings, NHS organisations must act with humility by acknowledging that mistakes can and do happen. They must be curious about why mistakes happened and take action to learn from them. And they must be accountable for putting that learning into practice and be open with families and staff about what has changed as a result.
The reality is that it is not possible to prioritise patient safety while avoiding difficult political decisions. Patient safety will always be at risk in environments that are understaffed, where staff are exhausted and the expectations of frontline NHS services change every time there is a new minister or leadership change.
This week marks 75 years of the NHS. It’s a time to look back on its achievements but also to look ahead at what needs to be done to overcome the challenges of the next 75. The question is whether there is the political courage to put patient safety on the priority list and keep it there for the long term.
