Monthly Archives: January 2016

Reflections on 2015

2015 has been a busy year for patient safety in the NHS

In March, the Morecambe Bay Investigation report was published.

The report marked the end of 6 years of effort by a number of families to understand how the failures at the maternity unit at Furness General Hospital (FGH) occurred, why they went unaddressed for so long and why so many lives were lost as a consequence.

In July, the government published its response to the Kirkup report, alongside its response to the Freedom to Speak up Review and the Public Administration Select Committee report ‘Investigating Clinical Incidents in the NHS. The response accepted all the Kirkup report’s recommendations.

2016 will see the publication of the Royal College of Obstetricians and Gynecologists (RCOG) ‘Each Baby Counts’ project. I am sure this important work will add to the momentum for improvements in the safety of maternity services. I am also encouraged by the announcement made by the government in November pledging to half the number or avoidable baby deaths in England.

The publication of NHS England’s National Maternity review is also expected in early 2016 and all in all, 2016 looks set to be an important year for maternity services with the need to improve safety and reduce avoidable harm high on the national agenda.

How the NHS responds to avoidable harm

One of the most powerful articles I read in 2015 was this piece from the patient safety correspondent at HSJ, Shaun Lintern.

The article highlights three examples of the experience of families affected by the avoidable loss of a loved one due to poor care.

Shaun wrote

“…rather than show them some humility and compassion, the NHS hurts them all over again. It is quite simply unspeakably cruel. Some positive steps have been taken towards a more open and transparent NHS, but so far these have relied on new regulation, beefed up codes of conduct and, as a last resort, new laws and threats of prosecution. The cultural change needed in the NHS will require a personal determination to act differently by everyone from frontline staff to individuals in system leadership roles.”

Shaun highlights that the three examples in his article are the tip of the iceberg and I am in complete agreement with him. 2016 must be a year of meaningful and lasting change.

Just weeks ago, the country was shocked by a report which looked at the deaths of people with a Learning Disability or a Mental Health problem in contact with Southern Health NHS Foundation Trust, between April 2011 to March 2015.

The report was sparked by the preventable death of Connor Sparrowhawk in July 2013. The agony for Connor’s family has been made so much worse by the way the trust responded to the appalling events that led to Connor’s unnecessary death. Now, largely thanks to the courage and determination of Connor’s family – a truth has emerged that clearly shows failures to investigate and learn from such events go far wider that Connor’s loss alone.

Healthcare is complex and we all must accept that from time to time, those working within it will make mistakes. Systems and processes should be designed and in place to minimise the chance of human error leading to harm, but when something as tragic as an avoidable death does occur, there can be no excuse for not doing everything possible to investigate, understand what happened and ensure lessons are learned to safeguard others.

The NHS and the principles it was founded on are rightly something our country should be proud of. In 2015, I experienced my father having to call an ambulance following chest pains. The ambulance arrived within 10 minutes, he was taken to A&E, given all appropriate tests and kept overnight in an immaculate ward, with kind and caring staff until given the all clear to go home the following day. He’s since had follow up outpatient’s appointments and has received an exemplary standard of care.

When I reflect on the short life and death of Joshua, after he collapsed at Furness General Hospital, the care he received in Manchester and later Newcastle, was second to none. During the 7 days Joshua spent at Newcastle, my wife and I witnessed the lives of other babies, some born with serious heart defects, being saved by truly remarkable people doing remarkable work. Those same staff came so close to saving Joshua’s life too.

We should celebrate and be proud that we have an NHS that at its best, provides world class, life-saving care to all. But however good the NHS can be, we should never accept variation in the quality of care such that for some people at some times, care is unsafe. Neither should we hold the NHS with so much reverence that we become blind and unwilling to acknowledge its problems.

The undeniable truth, however uncomfortable it may be, is that across the NHS as a whole there remains considerable variation in how safe the provision of care is. For all its strengths, the NHS is still way behind the kind of safety culture that exists in other high risk sectors and the truth is, as Shaun Lintern’s article so powerfully highlights, too often the way the NHS responds to mistakes and avoidable harm leads to further suffering for families and means that learning simply doesn’t happen.

The direction of travel

Facing up to these issues is a real challenge, both for the many dedicated professionals who work in the NHS day in day out but also for politicians of the day. In the past, former Secretaries of State for Health have described a need to maintain public confidence in the NHS and the Department of Health has been accused of acting like a ‘denial machine’ .

Certainly this echoes my experience following my son’s death in November 2008 and facing obfuscation in trying to establish what happened, followed by system wide denial that there were serious risks to mothers and babies at FGH until much too late.

Over the past few years the direction of travel has shifted markedly. There has been a real drive to improve transparency, both through a more robust and independent regulatory system, new laws around openness and candour and national movements like Sign up to Safety, which support individual healthcare providers to develop safety improvement plans aimed at reducing avoidable harm.

There is a long way to go but the NHS is already in a different place to where it was just a few years ago. A consequence of these changes is undoubtedly an increased awareness of the problems with variation, both in quality and safety and the deep rooted cultural issues that clearly exist. We must not conflate this increase in awareness with a belief that things have suddenly got worse. If we are to have any hope of making lasting change, we need to start by being honest about where we have come from and where we need to get to.

I do think that it’s right (as someone who has voted Labour in the past) to acknowledge that the current Secretary of State for Health has probably done more than any other Health Minister in history to prioritise reforms in the interests of patient safety.

2016 now looks set to be a hugely important year for the NHS and patient safety. In April, a new national patient safety investigations body will be set up. No other healthcare system in the world has an equivalent body. The new National Freedom to Speak Up Guardian  will be set up with local ‘speak up’ guardians in every provider organisation supporting staff to raise any concerns about safety in a safe environment .

The NHS has been described as a ‘supertanker’ and whilst these measures by themselves will not turn things around overnight, they are part of number of incremental steps that have a potential to make a real difference.

2016 will also see the merger of the TDA and Monitor (together with the safety functions that currently sit within NHS England) into NHS Improvement. All eyes will be on this new organisation and how it will work within the system to most effectively support organisations to improve.

Further Hopes for 2016

There is an urgent need to transform the way the NHS responds and learns from avoidable harm. The new patient safety investigations body has the potential to make a big difference, but it can only be part of the solution. Ombudsman reform, commitment from individual organisations, the litigation system and regulation all must pull in the same direction to support change. Central to this is ensuring that staff who make genuine mistakes always feel safe to report and be open and honest about them. Families affected by avoidable harm should always be treated with compassion and care. The science of Human Factors is fundamental (click here for one of best articles of 2015 about Human Factors and healthcare).

2015 has seen some difficult tensions between the Department of Health and the BMA over proposed changes to the junior doctor’s contract. This dispute has the potential to detract from other important issues where the focus needs to be. There is a strong case for strengthening 24/7 provision in our hospitals. There have been a number of studies in the last 5 years pointing to a ‘weekend effect’.  Whilst it is clear that many dedicated doctors and other NHS staff already work at weekends, the current system can make  it hard and expensive for trusts to properly organise and rota their  staff across 7 days. As Bruce Keogh has said, the current system operates on good will, rather than good design. In the interests of patients, I hope that in early 2016, the BMA will work to reach a fair agreement over changes to the junior doctor’s contract through negotiation and that strike action can be avoided.

Some thanks….

In December, my book ‘Joshua’s Story’ was published. A huge thanks again to everyone mentioned in the acknowledgments of the book, especially to Murray Anderson-Wallace, Anne Wallace and Roland Denning for all their help and hard work. I am hugely indebted to Phil Hammond, Peter Walsh, Jenni Middleton and Shaun Lintern for their support. The response to the book has been lovely and receiving positive feedback has meant so much.

A huge thanks and congratulations to Martin Bromiley on being recognised in the Queens New Years Honours list. Martin is one of the most inspiration people I’ve ever met and his recognition could not be more deserved.

Finally, thanks to all the many people, patients, campaigners, NHS staff, academics, civil servants and politicians who are all working hard to bring about much needed change and improvements in patient safety.

Wishing everyone a happy New Year and hoping that 2016 brings about further much needed changes and improvements in patient safety.


James Titcombe

January 2016