In any field of professional endeavour there comes a time when members and profession leaders need to pause and reflect on what they do and take stock.
To ask, where are we, what are we doing and where are we going? Is what we are doing still worthwhile? Are we effective and still fulfilling our purpose? Or, most worryingly, have we met our ‘Waterloo moment’? Are we meeting our ultimate obstacles and being roundly defeated by them?
Some recently published NHS patient safety reports have raised all these questions in my mind when thinking about the current states of NHS patient safety.
Report on maternity and neonatal services in East Kent
The first report to cause me to pose these questions is the long-awaited report by Dr Bill Kirkup (Kirkup, 2022) into the events at the maternity and neonatal services in East Kent. This has just been published and it makes for dire reading. This is compounded when the report is also read alongside Kirkup's previous report into events at Morecambe Bay (Kirkup, 2015). Even though these reports concern maternity care, they have important implications for nurses and doctors in other care areas.
A patient safety groundhog day
Feelings of being in a patient safety groundhog day wash over the reader when reading this latest report (Kirkup, 2022). This feeling is accompanied by an alarming sense of hopelessness about the effectiveness of our patient safety regulatory systems and how far we have gone towards developing an NHS patient safety culture.
The poor attitudes displayed by some health carers in the reports towards patients and each other, and the chronicled, systemic failings identified, all call into question how much learning about patient safety has taken place in the NHS or at least in substantial pockets of it.
We cannot say East Kent is a one-off exceptional event, an outlier. We have had Morecambe Bay, Telford and Shropshire to name just some recent investigations; Nottingham is ongoing. The recently published Care Quality Commission (CQC) ‘state of care’ report CQC (2022a) puts this issue in perspective, stating that, in maternity care, the pace of progress to improve has been too slow, despite a wide range of policies and initiatives to improve quality and safety. The situation is getting worse – an alarming indictment of an essential NHS care area:
‘In fact, our ratings as of 31 July 2022 show that the quality of maternity services is getting worse, with 6% of NHS services (9 out of 139) now rated as inadequate and 32% (45 services) rated as requires improvement. This means that the care in almost 2 out of every 5 maternity units is not good enough.’
To put this issue in some sort of perspective, two out of every five maternity units in England are not good enough according to the CQC ratings. In a modern, highly developed nation such as England, this a very sad and worrying situation and is compounded by the damning reports of Kirkup (2015; 2022).
We all need to ask how such poor events could be left to unfold and cause so much harm to patients, their loved ones, and babies in a modern-day NHS that has so much regulation. People have been seriously harmed by those who were meant to care for them. This is, by any definition of the term, a betrayal of trust by health carers and saps public confidence in the NHS.
There are broader patient safety lessons to learn from the Kirkup reports that are applicable to other clinical specialties. We all need to look at the essential themes identified and reflect on our own professional care areas, saying could this happen here?
The 2022 Kirkup report findings
It is stated in Kirkup (2022) that the inquiry investigating panel found a clear pattern which had led to problems:
‘Over that period, those responsible for the services too often provided clinical care that was suboptimal and led to significant harm, failed to listen to the families involved, and acted in ways which made the experience of families unacceptably and distressingly poor.’
The report states that the poor behaviour of some staff providing services, collectively and individually, was known to senior management and that there were missed opportunities to deal with staff behavioural problems. These behaviour issues the report states, ‘lay at the root of the pattern of recurring harm’. The outcome of the trust's failure to deal with the problems are stated in the report as being ‘stark’:
‘Had care been given to the nationally recognised standards, the outcome could have been different in 97, or 48%, of the 202 cases assessed by the Panel, and the outcome could have been different in 45 of the 65 baby deaths, or 69% of these cases. ‘The Panel has not been able to detect any discernible improvement in outcomes or suboptimal care, as evidenced by the cases assessed over the period from 2009 to 2020. ‘We have no doubt that these numbers are minimum estimates of the frequency of harm over the period.’
Lessons
The report has a wealth of detail and examples of patient safety failings that can inform all areas of clinical practice.
Poor teamworking
Poor teamworking is often a contributory factor in healthcare adverse patient safety incidents across NHS clinical care. Kirkup's report (2022) gives stark examples:
‘Poor teamworking was raised as a prominent feature by many of those we interviewed. Some obstetricians had “challenging personalities … big egos … huge egos”. Midwives showed “cliquey behaviour” and there was an in-group, “the A-team”. This behaviour was displayed “in front of women”.’
The reference to cliques and the A team in the above quote is an interesting one because a similar term can be found in the Morecambe Bay inquiry (Kirkup, 2015).
In Kirkup (2022) we had the ‘A team’ and in Kirkup (2015) we had the musketeers:
‘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’.’
Challenging staff personalities, cliques, bullying, professional tribalism, staff rudely complaining about issues in front of patients are all unacceptable behaviours identified in the report. I would argue that, to a lesser extent, some degree of what was found in Kirkup (2022) can also be seen in other clinical areas in the NHS. Bullying and challenging staff personalities have all featured in past CQC investigation reports.
Clinical hierarchies
Clinical hierarchies can cause problems and this issue has come up in relation to Never Events in surgery. The Healthcare Safety Investigation Branch (HSIB) (2021) discussed culture and safety and differing professional norms and values which could have an impact on safety:
‘Interview evidence suggested that it was accepted practice amongst teams for a surgeon to leave theatre before the end of a procedure. A scrub nurse said that in general there were occasions when those who were present for the procedure were not all present for the WHO sign out.’
This is clearly an immensely different example in terms of degree from the events chronicled in Kirkup (2022), but the point is that professional beliefs, practices and clinical hierarchies could translate into patient harm and that this can apply across all care areas.
Failures of professionalism
Failures of professionalism feature strongly in Kirkup (2022). As in all professions, the needs of clients, the people we have contact with, must come first. Kirkup (2022) identifies serious failings:
‘We found clear and repeated failures to uphold these principles. Staff were disrespectful to women and disparaging about the capabilities of colleagues in front of women and families. A family member heard a consultant describe the unit they were in as “unsafe” to a colleague in the corridor, which was hardly the way to raise any legitimate concerns they may have had.’
The events chronicled in Kirkup (2022) are extreme, but it is worth noting that nurses and doctors talking in front of patients can in certain circumstances cause problems. Patients don't want to be seen to be invisible when conversations take place in front of them, and they also must be treated respectfully, as the CQC (2022b) has stated.
Failure of compassion
Kirkup (2022) made the point that technical competence by itself is not good enough when treating patients. There is also a need to show compassion and kindness. Shocking examples of uncompassionate care were heard by the investigation panel in Kirkup (2022):
‘A woman who asked for additional information on her condition during an antenatal check was dismissively told to look on Google.’
Failures to listen
It goes without saying that good care giving also involves listening to what patients have to say. This point is discussed more broadly in CQC (2022b). Kirkup (2022) found repeated failures to do this.
Failures after safety incidents
After a patient safety event has occurred, good responses, explanations, meaningful apologies by all staff involved are fundamentally important (NHS Resolution, 2022). If responses are seen by the patient as being too defensive they can force them down the litigation and complaint route as they try to find out the true reason why something has gone wrong.
It has been said by several commentators in past patient safety reports that the NHS is generally too defensive when mistakes are made. Kirkup (2022) states:
‘We found that the same patterns of dysfunctional teamworking and poor behaviour marred the response by staff after safety incidents, including those incidents that led to death or serious damage. Although some staff were caring and sympathetic, and this was recognised and welcomed by families, others were not.’
Kirkup, 2022; 5
These are just some failings among several others discussed in the report.
Conclusion
The publication of Kirkup (2022) should be viewed as a wake-up call for everybody who works in the NHS. The report should not be limited in reading and application to maternity and neonatal care staff and units. There are some general NHS patient safety lessons to be learnt from it.