There does not seem to be a week that goes by without an NHS patient safety crisis hitting the headlines and this has been the case for many years. The NHS has built up a huge back catalogue of reports from major inquiries into patient safety crises, spanning decades. These contain a lot of deep thinking, useful analysis and valuable recommendations. Some recommendations are implemented but not all. Timmins (2018) neatly catalogued the causes of patient safety failures identified in past inquiry reports:
‘Professional and/or geographic isolation. Weak leadership. Interpersonal, and sometimes inter-professional, conflict. Failures in communication. A reluctance to listen to patients, families and staff. Denial in the face of the evidence and bullying of those who raise concerns. All of which can lead to a normalisation of the abnormal. Plus, in some cases an over-focus on finance at the expense of care and quality … “When will we ever learn?” is a common refrain from those who examine the impact of previous inquiries.’
I would fully echo Timmins' (2018) words; the same patient safety issues do keep being repeated and lessons do go unlearnt. There is no obvious sign of this trend changing if recent media reports of patient crises are anything to go by. There is a need for a system-wide rethink on how we can make the NHS culture less defensive when adverse patient safety incidents occur and how lessons can be learnt, and practice changed.
Reviewing patient safety crisis inquiry reports is a useful exercise in developing effective patient safety policy and in educating staff. Some of the seemingly intractable, stubbornly persistent patient safety problems that beset the NHS, both past and present, are identified and discussed. Revisiting reports analysis can also refresh our perspective on patient safety issues and provides an information bedrock on which we can base change. Several reports will be discussed below to illustrate this.
Momentum for change
Patient safety inquiry reports also provide a momentum for change through their recommendations, which the government of the day can accept or reject. The Government accepted most of the recommendations made in the Francis Report (2013) on the situation at Mid Staffordshire.
‘There is, of course, a challenge here. Governments should, of course, implement the desirable and implementable (itself a matter of judgement) while rejecting or quietly shelving the less wise or over-burdensome. But after the government's formal response to a report there is no established follow up mechanism to see whether what has been promised in fact happens. Some inquiry chairs do pursue government over their findings. Others understandably return to their day job.’
Following the Francis Report, the NHS did make determined efforts to implement changes but that has not stopped major patient safety crises developing. The problem seems to be developing sustainable culture change at the Trust and workplace levels. The NHS is not developing fast enough an intrinsic patient safety culture.
The Kennedy Report
In 2001, a long time before the Mid Staffordshire crisis, we had the report of the public inquiry into children's heart surgery at the Bristol Royal Infirmary during 1984-1995, commonly known as the Kennedy Report. This report is as relevant today as it was when first published, and is still a useful patient safety policy and educational aid.
The report (Kennedy, 2001) captures the essential patient safety problems that later faced the NHS with Mid Staffordshire (Francis, 2013) and which faced us again with more recent patient safety crises such as Morecambe Bay (Kirkup, 2015) and Liverpool Community Health (Kirkup, 2018; Department of Health and Social Care (DHSC), 2019).
The Kennedy report laid down some foundational patient safety concepts. The essential features of a culture of safety were described and included:
‘Concern for the safety of patients should be embedded in the NHS as a whole and be the responsibility of everyone who works in a trust.
There must be an awareness and understanding of safety and an appropriate means of managing issues relating to safety at all levels of the NHS.
Human fallibility is an inescapable reality: thus, systems are needed to anticipate all types of adverse event, to eradicate them where possible and mitigate their effects.
A mindset of constant vigilance is crucial.’
Also included in this list of essential features is the importance of maintaining a non-punitive working environment in which it is safe to admit and report adverse events or errors. Fear, it was argued, is the enemy of safety. Also that adverse events offer opportunities to learn and to make changes to clinical practice, not an occasion to punish and forget.
The Kennedy Report (2001) contains the foundational principles that patient safety in the NHS and in other countries should be built upon. The report is a long and detailed one, running to 530 pages, but key chapters in section 2—such as chapter 22 on the culture of the NHS, or chapter 26 on the safety of care—are still very relevant to the NHS today. There have been some changes to the patient safety environment since the time the report covers but many of the endemic patient safety problems stubbornly remain as they did when the report was first published. We can see the recurring nature of the patient safety problems identified in Bristol in subsequent reports.
Morecambe Bay
The Morecambe Bay Inquiry (Kirkup, 2015) was an independent investigation into the management, delivery and outcomes of care provided by the maternity and neonatal services at the University Hospitals of Morecambe Bay NHS Foundation Trust from January 2004 to June 2013. The introduction of the report clearly identifies major failings:
‘The result was avoidable harm to mothers and babies, including tragic and unnecessary deaths. What followed was a pattern of failure to recognise the nature and severity of the problem, with, in some cases, denial that any problem existed, and a series of missed opportunities to intervene that involved almost every level of the NHS. Had any of those opportunities been taken, the sequence of failures of care and unnecessary deaths could have been broken.’
Common patient safety failure themes are revealed that can be seen in many previous reports: poor record keeping, poor working relationships, dysfunctional working environments, lack of leadership, poor management practices, defensive culture.
The continuing cycle of patient inquiries: the latest
The DHSC has just announced, on 6 June 2019, a new independent inquiry into the serious incidents in community-based health services run by Liverpool Community Health NHS Trust between 2010 and 2014, (DHSC, 2019). The report of the announcement in The Guardian contains some very worrying figures regarding the scale of the problem:
‘Ministers have ordered an inquiry into evidence that an NHS trust failed to properly investigate 150 patient deaths and 17 000 incidents in which patient safety was put at risk. The investigation is the latest in a series of inquiries into the care provided by Liverpool Community Health (LCH) NHS Trust. They all found serious problems including shoddy treatment, bullying and failures of leadership.’
The investigation will be conducted through three stages (DHSC, 2019). The inquiry will seek to identify individual serious patient safety incidents that were not reported or adequately investigated, then undertake a series of historical mortality reviews. At stage 3 the inquiry will fully investigate incidents identified in stages 1 and 2. The inquiry will determine the scale of patient harm and identify local and national lessons to be learnt from the events.
This will be the second inquiry into Liverpool Community Health conducted by Dr Kirkup. The first report found serious dysfunctionality in the trust:
‘Demoralised staff were badly treated and sometimes bullied, and there was a failure of nursing management and HR procedures. Serious incidents causing patient harm were not reported, not investigated and lessons not learned. The result was unnecessary harm to patients.’
I do not doubt this second investigation will reveal a catalogue of patient safety failings, which will most probably have been seen before in previous patient safety inquiry reports over the years. The local and national learnings will also, no doubt, be very familiar. Recurrent learning points will be, I would expect, the need to maintain safe staffing levels, good leadership and staff management practices. No bullying, good patient caring and not focusing inordinately on financing. Putting patients first, reflective and safe practice, improving communication skills at all levels, avoiding defensive attitudes when things go wrong, and so on.
Conclusion
An important patient safety education journey can be taken by reading the report into Bristol Royal Infirmary and others such as Mid Staffordshire, Morecambe Bay, Liverpool Community Health and attempting to compare and contrast the findings and recommendations made. An attempt should be made to try and join up all the valuable thinking that has gone on before.
It is readily acknowledged that there are many published patient safety inquiry reports; my suggestion would be to select a few key reports to read in order to get a true sense of the repetitive, cyclical nature of NHS patient safety problems. The same patient safety problems always seem to be happening, the same type of solutions being proffered. Lessons from past adverse events seemingly go unlearnt and a defensive culture always seems to prevail when things go wrong.
This exercise will hopefully also bring some fresh new perspectives to old and new problems. We do need to develop much more of a sense of NHS patient safety history and not always follow the seemingly innate NHS tendency to reinvent the wheel when there are already existing intelligence and solutions presented in past inquiry reports.
The patient safety inquiry reports of the past should not be forgotten or ignored, they have an intrinsic value and an important role to play in helping develop an ingrained NHS patient safety culture.