Issue 1: How can the Healthcare Industry learn from incidents?
The report into the deaths of more than 450 patients at Gosport War Memorial Hospital between 1987 and 2001 has found “there was a disregard for human life and a culture of shortening the lives of a large number of patients by prescribing and administering ‘dangerous doses’ of a hazardous combination of medication not clinically indicated or justified.” At least another 200 patients were probably also affected. This case, like others with similar issues at their core, has sent shockwaves across the health and social care organisations.
Questions have been asked about how this was able to happen and why have lessons seemingly not been learnt from past scandals. After similar notorious events that have occurred since and the inquiries and reports that followed (Bristol Royal Infirmary, Alder Hey, Dr Shipman, Winterbourne, Maidstone and Tunbridge Wells, Mid-Staffs, Mr Paterson, Southern Health, etc.) it was declared that lessons were identified and recommendations made, and responses from Government followed. The question that remains is where is the verifiable evidence to prove that those organisations involved in the next scandal acted on the recommendations from the one before it, and is there any evidence that changes since would prevent another scandal from happening, both for them and the rest of healthcare and social care?
Today there are many systems and processes in place to enable and encourage learning from incidents and that poor, inconsistent or unusual standards of care can be detected e.g. Serious Incident investigations, Duty of Candour, Prevention of Future Death reports, National Guardian’s Office, CQC regulations, clinical audit, peer review, revalidation, etc. High quality care and system improvements can be found in many organisations all over the country. This would indicate that learning can be implemented but for some reason, not consistently across the healthcare landscape.
Sir Ian Kennedy, as chair of the Bristol Royal Infirmary Inquiry said in the foreword of the report, “It would be reassuring to believe that it could not happen again. We cannot give that reassurance. Unless lessons are learned, it certainly could happen again, if not in the area of paediatric cardiac surgery, then in some other area of care. For this reason we have sought to identify what the lessons are and, in the light of them, to make recommendations for the future.” The fact that Kennedy was asked back to Bristol in 2014 to again look at the death rate of paediatric cardiac patients demonstrates the inconsistency of learning lessons.
In the 1980s and for most of the 1990s formal systems for healthcare organisations to monitor or assure patient safety or quality of care were at best fragmented and inconsistent: value was placed on professional autonomy and self-regulation, and challenges to behaviour or practice standards weren’t expected or encouraged by any regulatory or governmental body with the vigour they are today. In 1997 that the concept of clinical governance was introduced into the NHS1 and Boards became formally accountable for clinical quality. The Gosport Inquiry has highlighted that the procedural and cultural norms at that time were contributory factors into the prescription and administration issues at Gosport War Memorial Hospital, but 20 years after the introduction of clinical governance, and since then integrated governance, how many more scandals have to be uncovered for the healthcare industry to become truly open and honest and as safe as practicably possible?
Southern Health NHS Foundation Trust has been responsible for services at Gosport War Memorial Hospital since 2011. In 2015 an independent review2 of Southern Health, into deaths of people with a learning disability or mental health problem, heavily criticised weak governance at the Trust amongst many other failures. The Gosport Inquiry Report has also criticised weak governance.
So what does it take to turn around the ‘organisational and cultural’ failures that the Gosport Inquiry highlighted during the 1987-2001 period but that are still present today over 20 years later?
It will take a comprehensive integrated governance approach alongside a culture of openness, honesty and integrity and there are plenty of systems and processes in healthcare to allow this to happen.
Unfortunately, one aspect that was not used in this instance was the application of Rule 43 of the Coroners Rules 1984, where the Coroner believes that action should be taken to prevent the recurrence of similar deaths. Now known as Prevention of Future Death reports (PFDs), if used as they were intended, these should be powerful implements for learning lessons and provoking change. The Gosport Inquiry showed that the coroner did not issue any Rule 43 letters because he felt that as the events occurred over 10 years ago a Rule 43 letter would not have been relevant anymore. This belief must surely be questioned. In fact, a review of the PFDs as a means to ensure lessons had been learnt from the time could still help to prevent reoccurrence in the future.
Although change on the whole in the healthcare environment may seem slow, the passion to create better quality and safer care has not abated. Prevention of Future Death reports have the potential to be a vital learning tool and their effectiveness will be looked at further in the next blog.
Caroline White
Healthcare Risk Control Director
[email protected]
1https://www.gov.uk/government/publications/the-new-nhs
2https://www.england.nhs.uk/south/wp-content/uploads/sites/6/2015/12/mazars-rep.pdf