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Putting patient safety first: how long will it take before the NHS learns from its mistakes?


One of the most powerful contributions to our Annual Conference was a presentation by James Titcombe, the father of Joshua, a baby boy who died aged only nine days after signs of his deteriorating condition were missed by the staff at Morecombe Bay NHS Trust. What was remarkable about James’s story is that he was able to draw valuable lessons from it about how the NHS could improve patient safety by learning from mistakes.

James presented data from a regional confidential inquiry into 25 cases of perinatal death. Only 24 per cent of the 140 possible contributory factors identified by the inquiry team had been identified in local investigations at the time of the incidents. So 76 per cent of the learning from the incidents had been missed; a situation that there is an urgent need to improve.

James said that we would only achieve Don Berwick’s ambition for the NHS to ‘place the quality of patient care, especially patient safety, above all other aims’ if we have candour when mistakes happen and acknowledge all medical errors. All mistakes/serious incidents must be properly investigated, with audited action plans that address the root causes. James said that if an NHS organisation makes a mistake that causes preventable harm to patients for a second time, it should be regarded as a ‘never event’. James also argued for the Care Quality Commission (CQC) to make greater use of investigations into serious untoward incidents in its assessments.

Since James presented to us, the government has issued its response to the Francis Inquiry report. But to what degree does this response address James’s recommendations? There is a lot that is relevant – as well as the new statutory duty of candour, the ‘cultural aspects of care’ will now form part of CQC’s inspection regime. Greater use will be made of incident data, including a commitment for CQC to consider each hospital’s review of serious untoward incidents as part of its pre-inspection activity. NHS England will also launch a programme of new patient safety collaboratives, which will be expected to provide expertise on learning from mistakes and help to provide a ‘rigorous approach to transforming patient safety’.

The key to success will be the degree to which these national aspirations are owned and adopted at local level, to create a culture that rigorously uses data to monitor quality and progress. Immediately before James spoke at our Annual Conference, we heard an inspirational speech from Dr Brent James, who talked about the systemic approach to quality improvement at Intermountain Healthcare and gave examples of initiatives that had made significant improvements in survival rates. At Intermountain all senior clinical and administrative staff are expected to be skilled in quality improvement. Brent stressed that ‘We count our successes in lives’.

How far is the NHS from this culture? In places like Salford Royal NHS Foundation Trust it feels not far. The trust has worked hard to skill clinical and non-clinical staff, specifically in quality improvement, systematically reviews its quality performance data and has managed to significantly reduce the incidence of avoidable harm. Sadly, this is a long way from the position in many trusts.

I spent yesterday at an event called Medicine Unboxed. It was a fascinating day. One of the most startling presentations was from Professor Roger Kneebone, a trained surgeon, who showed an anonymised film of an operating theatre. Loud music was being played, so much so that the words of those conducting the operation were not being heard or properly understood, a sharp contrast to the requirement for aircraft cockpits to be silent at take-off and landing. To me this exemplified a culture that does not put patient safety above all else. A graphic example of the distance the NHS has to travel before we see making the same mistake twice as a ‘never event’.