The Operating Theatre Journal - Flipbook - Page 4
NHS must accept
accountability and learn
from mistakes
The National Health Service is suffering
from a deficit of accountability and
compassion for patients and their families
when things go wrong, England’s Health
Ombudsman has warned.
We need to see significant improvements in
culture and leadership. However, the NHS
itself can only go so far in improving patient
safety. One of the biggest threats to saving
lives is a healthcare system at breaking point.
In a new report, ‘Broken trust: making
patient safety more than just a promise’,
the Ombudsman has said the NHS must do
more to accept accountability and learn from
mistakes, particularly when there is serious
harm or, worse, loss of life.
“The Government says patient safety is a
priority but, if it means this, the NHS must
be given the workforce capacity it needs.
We need to see concerted and sustained
action from Government to support NHS
leaders to prioritise the safety of patients.
Patient safety must be at the very top of the
agenda.”
When concerns are raised after such
incidents they are too often met with a
defensive attitude. This makes things even
worse for a grieving family trying to get
answers. It also places unnecessary pressures
on staff, creating a barrier to learning and a
gateway to making the same mistakes.
Despite significant progress made on patient
safety in the last decade, ten years on from
the Francis inquiry into failings in care in MidStaffordshire, we are still seeing too many
preventable tragedies. The Parliamentary
and Health Service Ombudsman (PHSO)
considered over 400 serious health
complaints from the last 3 years and found
22 cases of avoidable death.
The Ombudsman has called for urgent action
from the Government to prioritise patient
safety and protect families who search for
understanding in the wake of a tragedy.
The report sets out recommendations to
improve patient safety. These include
better support for families affected by harm;
embedding cultures that promote honesty
and learning from mistakes; getting the
right oversight and regulatory structures to
prioritise patient safety; and an evidencebased and long-term workforce strategy that
has cross-party support.
Ombudsman Rob Behrens said, “Mistakes are
inevitable. But whenever my office rules that
a patient died in avoidable circumstances,
it means that incident was not adequately
investigated or acknowledged by the Trust.
“Every time an NHS scandal hits the front
pages, leaders promise never again. But the
NHS seems unable to learn from its mistakes
and we see the same repeated failings time
and time again. Our report looks at the
reasons for the continued failures to accept
mistakes and take accountability for turning
learning into action.
The report examines cases investigated by
PHSO where patients died due to avoidable
errors. Often these incidents were caused
by issues such as failing to make the right
diagnosis, treatment delays, poor handovers
between clinicians, and failing to listen to
the concerns of patients and their families. In
every case we looked at the NHS had failed to
properly investigate what had gone wrong.
In one case, doctors at Bradford Teaching
Hospitals NHS Foundation Trust failed to
identify a man’s pulmonary embolism.
Christopher Walmsley, 44, was diagnosed
with pneumonia despite there being no
evidence of this and showing symptoms of
a pulmonary embolism. He was sent home
without the right treatment and died of a
cardiac arrest.
The Trust’s own investigation did not find that
failures in Christopher’s care led to his death,
however the Ombudsman found his death
could have been avoided if the right diagnosis
had been made.
His mother, Patricia Walmsley, said, “He
died in his bedroom, and I had to hear it. My
grandson was in the room with me, and he
heard him die too. It’s not something that
you would wish anyone to go through.
“When we received the Trust’s letter in
response to the PHSO investigation, we felt
a lot better because it was official that they
hadn’t done everything that they could have.
We were glad we had that vindication.
“I just looked up and said, ‘my son, we’ve
done the best for you that we can’. Wherever
he is, he knows that we didn’t just let it
drop. It won’t bring him back, but it might
stop somebody else from going through the
same thing.”
In another case, a woman with a history of
self-harm and suicide attempts killed herself
after staff at Wotton Lawn mental health
unit failed to observe her as frequently and
closely as they should. However, the Trust’s
own serious incident investigation found
that their actions did not cause harm to the
woman.
The woman, who had schizophrenia and
emotionally unstable personality disorder,
was a long-term patient and had been
prevented from self-harm twice in the three
days before she died.
However, following these incidents staff at
Gloucester Health and Care NHS Foundation
Trust failed to update her risk assessment
to include actions to reduce risks and avoid
further harm.
A day after the second self-harm incident, the
woman was found unresponsive. She never
regained consciousness and died 18 days
later.
The report also includes the case of a baby
who died after antibiotics were not given
quickly enough. We found that University
Hospitals Bristol and Weston NHS Foundation
Trust had not properly equipped its staff to
acknowledge what had gone wrong.
Important details about the sequence of
events and the nature of the infection were
not given to the parents until seven weeks
after their son died.
Staff even discussed deleting a recording
made during a meeting when the parents
temporarily stepped out of the room,
because they realised what they had said
might get the Trust into difficulty.
This complete failure of transparency created
understandable mistrust and worsened the
pain and distress of the family in their grief.
To read the report visit: https://www.
ombudsman.org.uk/publications/broken-trustmaking-patient-safety-more-just-promise
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