The NHS is littered with examples of cases where individuals and organisations have seemingly buried their heads in the sand when patient safety errors have occurred. Attitudes range from refusing to take responsibility, assuming that another organisation is dealing with the matter, delaying a response or even ignoring the situation completely. Failure to report a patient safety adverse incident may be because of the fear of disciplinary consequences and this has been well chronicled. There may also be other reasons why adverse patient safety incidents are not dealt with properly.
The Mid Staffordshire Public Inquiry identified a negative, engrained Trust culture, which included a tolerance of poor standards and denial of concerns:
‘While it is clear that, in spite of the warning signs, the wider system did not react to the constant flow of information signalling cause for concern, those with the most clear and close responsibility for ensuring that a safe and good standard care was provided to patients in Stafford, namely the Board and other leaders within the Trust, failed to appreciate the enormity of what was happening, reacted too slowly, if at all, to some matters of concern of which they were aware, and downplayed the significance of others.’
All these attitudes are unforgivable when an avoidable injury has happened to a patient. Breaches of the professional and statutory duties of candour can also occur. The events at Morecambe Bay are also a salutary reminder of the failures in this area:
‘Many of the reactions of maternity unit staff at this stage were shaped by denial that there was a problem, their rejection of criticism of them that they felt was unjustified (and which, on occasion, turned to hostility) and a strong group mentality amongst midwives characterised as ‘the musketeers’. We found clear evidence of distortion of the truth in responses to investigation…’
Towards a just NHS culture
A constant NHS clarion call is to develop a ‘just culture’. We cannot have a totally blame-free culture as some patient safety errors will require fault to be personally attributed and disciplinary action may follow. The NHS is seen as having a predominantly defensive culture when patient safety errors have occurred—this has to change.
The Mid Staffordshire and Morecambe Bay crises indelibly blotted the NHS patient safety landscape but they were not the only Trusts to suffer from what I term the ‘ostrich syndrome’. This is a feature evident in many reports that address patient safety failings in hospitals and elsewhere.
Two recent reports shine a light on this area of proper action taking and responses when patient safety errors are made.
Paterson Inquiry report
The Paterson scandal, involving over 1000 inappropriate or unnecessary operations carried out by a surgeon, has been a story that has rocked the public's confidence in health care once again, and made headlines when the Paterson Inquiry, chaired by the Right Reverend Graham James, published its findings:
‘Paterson was free to perform harmful surgery on mainly female patients in NHS and private hospitals because of “a culture of avoidance and denial” in a “dysfunctional” healthcare system where there was “wilful blindness” to his behaviour.’
The inquiry report (James, 2020) identifies many familiar patient safety failure themes. It begins with a sad indictment of our healthcare system, stating that it is itself dysfunctional at almost every level when it came to keeping patients safe and patients were repeatedly let down.
An unfathomable system
The report discusses the complexity of our healthcare regulatory system:
‘This report is primarily about poor behaviour and a culture of avoidance and denial. These are not necessarily improved by additional regulation. The sheer number of regulatory bodies and the complexity of their areas of responsibility meant that Paterson's patients thought the system unfocused and scarcely possible to navigate, while many clinicians seemed to feel the same, and so avoided engagement with it.’
A fundamental disconnect
I would agree with these comments. Our patient safety system is an over-engineered and complex one. It hosts a myriad of competing organisations and stakeholders with overlapping functions and agendas. To those at the centre of policy making it might seem an effective and well-crafted system and here lies the central problem, in my view. Members of the public and nurses and doctors at the coalface may well see things differently. There is an apparent disconnect between those who run the patient safety regulatory system and those who are directly affected by it. The report captures that disconnect, with comments such as ‘system dysfunctionality’ and ‘complexity’.
The risk of desensitisation
If those who make patient safety policy decisions do not step out of role and reflect on how people in the street view the system then there will be problems. They risk becoming desensitised to the central issues. Those who are engaged with the system for a long time will begin to lose objectivity, become too used to the many acronyms and bodies that inhabit the NHS health regulatory and patient safety landscape. To the average nurse, doctor or patient I would say our health governance, and patient safety system is largely unfathomable, and I would fully support the view expressed by the inquiry's chair.
The report makes several key recommendations, which include:
‘Despite the scale of the regulatory system, it does not come together effectively to keep patients safe. We also heard that it is not accessible or understood by patients. We do not believe that the creation of additional regulatory bodies is the answer to this. We recommend that the Government should ensure that the current system of regulation and the collaboration of the regulators serves patient safety as the top priority, given the ineffectiveness of the system identified in this Inquiry.’
Patient safety alert improvement
The UK charity for patient safety and justice, Action against Medical Accidents (AvMA), has recently published a highly critical report on patient safety alerts, implementation, monitoring and regulation in England (Cousins, 2020). Serious problems are identified with the system of issuing patient safety alerts and monitoring compliance with them—and serious delays in NHS trusts implementing patient safety alerts.
One major concern identified is that the governance arrangements for the implementation of patient safety alert guidance within many individual trusts is still poor:
‘The role and responsibility of national organisations to oversee the implementation of these alerts was unclear and ineffective in some cases.’
There can be significant delay in implementing alert guidance and in some cases, years can elapse.
Cousins (2020: 23) points out that the Care Quality Commission (CQC) has no central database of non-compliance or action being taken about non-compliance with alerts. This information is held at the local level, and ‘it is not clear whether any proactive action is taken to try to ensure trusts comply’.
Reasons for delay
There is a discussion of the reasons given by trusts for delays in implementing patient safety alert guidance. The summary of trust responses includes:
It is possible to understand the above reasons for delay in a resource-constrained NHS healthcare environment. However, the feeling I get from these is that the alert system needs to be viewed as a more urgent priority by trusts. Delay can indicate that the alert guidance has been parked for an indefinite time and there are other priorities. Staffing can lead to delay but ‘business case approval’—how long should that take? Would there ever be a case of a change to address a patient safety alert failing business case approval? This unfortunately smacks of the problems of Mid Staffordshire and patient safety falling through the cracks because of a prime focus on financial issues.
Other findings include insufficient transparency on major risks, including ‘known/wicked risks’, to patient safety reported to the National Reporting and Learning System (NRLS). The remit of the patient safety team and the NRLS in NHS Improvement is not clearly documented to enable understanding externally. A more robust and proactive system of monitoring and regulating compliance with patient safety alerts in primary, secondary and community sectors is required.
Conclusion
The ostriches appear to alive and kicking in some sectors of the NHS, and as the Paterson events show in private health care as well. There are important lessons to be drawn from the Paterson Inquiry (James, 2020). It is concerning that the regulatory system was not seen to be coming together effectively to keep patients safe, and that it is not accessible or easily understood by patients and health professionals alike.
The AvMA report (Cousins, 2020) shines a bright light on patient safety alerts, implementation, monitoring, and regulation. The reasons for delay in implementing guidance are particularly worrying. I wonder how members of the public would feel when they see mention of ‘business case approval’. I would not fly as a passenger on an airline that delayed implementing a safety alert in order to carry out a business case analysis for safety. The findings illustrate the apparent disconnect that I discussed between the masters of the NHS quality and patient safety systems, at local and national levels, and what individual members of the public and, I suspect, nurses and doctors would objectively expect for the implementation of alerts. There is a serious disconnect in reasonable expectations, and I would say objective realities.