COMMENT


Facing difficult truths


Editor LOUISE FRAMPTON


louiseframpton@stepcomms.com


Contributing Editor SUZANNE CALLANDER


Technical Editor KATE WOODHEAD


Business Manager Online CHRIS VINCENT


chrisvincent@stepcomms.com


Publisher GEOFF KING


geoffking@stepcomms.com


Publishing Director JOSH TAYLOR


joshtaylor@stepcomms.com


Journal Administration KATY COCKLE


katycockle@stepcomms.com Design


STEVE DILLON


THE CLINICAL SERVICES JOURNAL is published in January, February, March, April, May, June, August, September, October and November by Step Communications Ltd, Step House, North Farm Road, Tunbridge Wells, Kent TN2 3DR, UK. Tel: +44 (0)1892 779999 Fax: +44 (0)1892 616177 Email: csj@stepcomms.com Web: www.clinicalservicesjournal.com


There has been a succession of reports investigating some of the most serious failures in NHS care, recently, which make distressing reading. In this issue, we report on some of the lessons that can be learned from the difficult truths uncovered – which include instances of abuse, dysfunctional relationships, poor clinical governance and leadership, failures to learn from mistakes and a culture of denial and self-protection when things went wrong. The Freedom to speak up review, led by Sir Robert Francis, identified


a culture, within many parts of the NHS, that deters staff from raising serious concerns. The Review includes a list of ‘Principles and actions’, which it says should be implemented by all organisations that provide NHS healthcare. One area relates to culture change and states that every organisation involved in providing NHS healthcare should actively foster a culture of safety and learning, in which all staff feel safe to raise concerns. The Secretary of State for Health, Jeremy Hunt, commented that the tendency


to ‘delay, defend and deny’ must change. This is certainly a common theme raised throughout the Morecambe Bay Investigation report, which also highlighted the need for openness, transparency and learning, when mistakes are made. The Morecambe Bay report investigated significant failures leading to the


deaths of three mothers and 16 babies at Furness General Hospital. The tragic consequences of a culture of ‘delay, defend and deny’ is most evident in this report, which describes the response to serious incidents as having been ‘grossly deficient’. Among the findings was the fact that there had been repeated failures to investigate


incidents properly and a series of missed opportunities to intervene that involved almost every level of the NHS. Had any of these opportunities been taken, the sequence of failures of care and unnecessary deaths could have been broken. However, they were still occurring after 2012, eight years after the initial warning event, and over four years after the dysfunctional nature of the unit should have become obvious. Not only were there numerous missed opportunities to learn from serious


incidents, but the investigation was also hampered by hostility, denial and even ‘disappearance of records’. In addition, the investigators found evidence of ‘inappropriate distortion of the process of preparation for an inquest’, including the circulation of ‘model answers’. The report acknowledges that to make mistakes is to be human. But it is also


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ISSN NO. 1478-5641


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human nature to have feelings of defensiveness and self-preservation in the face of perceived ‘criticism’ – even when that criticism is justified. Being open and transparent about mistakes requires staff to feel safe and protected; it needs to be part of their everyday culture and training. Sharing and learning from mistakes must become second-nature, so that it is the ‘default’ response, which everyone understands is for the greater good. Above all, staff need to feel confident that ‘learning lessons’ is about saving lives and not about blame. Creating such a culture will be challenging for healthcare providers and regulators


alike; as individuals, it also requires professionalism and compassion to triumph over the equally human characteristics of self-interest and ego – and this will be a very personal and private challenge for each and every member of staff tasked with the care of patients on the frontline.


LOUISE FRAMPTON Editor


Follow us on twitter: @csjmagazine APRIL 2015 THE CLINICAL SERVICES JOURNAL 5


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