Parliamentary and Health Service Ombudsman
As the year draws to a close, it’s an appropriate time to reflect on the work we’ve done over the last year to drive improvements in patient safety.
I wanted to share some of the many examples over the past 12 months which have been particularly pertinent. They illustrate the importance of what we do to drive improvements and change in public services.
Restoring trust in patient safety
Patient safety is the key issue in the NHS. We published our report, Broken trust: making patient safety more than just a promise in June 2023. It created the evidence-base, publicity and momentum for a sustained campaign to draw attention to avoidable death, and the sub-optimal culture and leadership that permeates much of the NHS.
The report reviewed our most serious patient safety cases and found recurring themes of clinical failings which led to avoidable deaths:
- failing to make the correct diagnosis
- treatment delays
- poor handovers between clinicians
- failure to listen to patients’ concerns.
These failures in care have led to harm. This is compounded by poor responses to families seeking to understand exactly what happened to lead to the loss of a loved one. When things go wrong, service users expect honesty and an apology. Too often, that is not their experience.
The Department for Health and Social Care (DHSC) has announced a review of the Duty of Candour, which I have long called for. Without routine honesty of staff when things go wrong, patient safety will remain second to organisational reputation.
The opportunity to contribute the expertise and evidence from my office to the review is welcome news, but there is much more to be done to make sure patients and their families receive the care they deserve.
Resetting NHS culture
The vast majority of people who work in the health service do so because they want to help and do the best they can to care for their patients. Our own clinical advisers, for example, are exemplary in their public service, ethical strength and determination to understand what has happened when people who use their service complain. Without them we would be significantly less effective and authoritative.
We have not been afraid to voice the widespread problem of fear and defensiveness within some parts of the NHS, and an inability to accept accountability and to learn from mistakes. This was further highlighted by the Lucy Letby trial and its aftermath. Too often we see the commitment to patient safety in the NHS undermined by a defensive leadership culture.
Following the Letby trial, I wrote to the then Health Secretary, calling on him to widen the terms of reference of the inquiry into events at Countess of Chester Hospital. The Secretary of State asked to meet me and widened the original terms of reference to include the broader issues of culture and leadership in the NHS, as I had suggested.
It is time to reset the culture of the NHS and make sure the voices of patients, their families and staff are heard. The Thirlwall inquiry is a step in the right direction.
Making patients' voices heard
Through our investigations we see many tragic cases where patients have died and the outcome might have been different if they, or their families, had been listened to.
The introduction of Martha’s Rule in hospitals across the country will play an important role in making sure those voices are heard. It will give people the power to seek an urgent second opinion if a patient's condition is deteriorating, or they have concerns about the standard of care being provided. It is a welcome change and I was pleased that PHSO was asked to play a key part in the discussions on how to make it happen.
But it’s not just patients that need to be listened to. Those caring for patients need to feel confident that when they raise concerns about patient safety, their concerns will be addressed. Patient safety must be a priority for all.
The power of complaints
Every time someone comes to us with a complaint about the NHS or a public service organisation, it is because they have been unable to reach a satisfactory conclusion. It also means they will probably have gone through an unacceptably long and painful process to make sure action was taken to address the problem and seek justice.
The PHSO-led NHS Complaints Standards have begun to professionalise frontline complaint handling so that it is consistent across the NHS. They will make sure that when things go wrong, people feel empowered to speak up about their experiences so that accountability is delivered, standards improve and the same mistakes do not happen again.
This is why the power of complaining is so important. Complaints can reveal truth, bring closure and create lasting positive change. The work we’ve done this year is a step on this journey and there is much more to be done in the forthcoming year and beyond.
I wish everyone a peaceful and happy 2024.
