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Progress in Patient Safety

The last few months have been a busy period for patient safety

James Titcombe Blog Progress

The last few months have been a busy period for patient safety, with several important changes being announced. I thought I’d write this blog to highlight some of these and share some reflections.

HSIB goes live!

On 1 April, the Healthcare Safety Investigation Branch (HSIB) went live. The story of how HSIB came to be is a fascinating and inspiring one. The need for an independent investigations body for healthcare has long been championed by organisations like the Clinical Human Factors Group (CHFG)  and individuals like Martin Bromiley. However, it was this paper in 2014 by Carl Macrae and Charles Vincent that really marked a turning point. Following this, the Public Administration Select Committee (PASC) carried out an inquiry which later made the recommendation that a new independent investigations body, modelled on the Air Accident Investigation Branch (AAIB) should be formed.

Those of us familiar with the usual pace of change in healthcare will know that going from an academic paper to a launch of a major new organisation in the space of a couple of years is pretty much unheard of. My view is that the establishment of HSIB is one of the most significant events in patient safety in the last 20 years and the rumours are that other countries are looking to follow suit.   

More information, including how to contact HSIB to make them aware about a patient safety event or concern is available here.

To correspond with the launch of HSIB, the authors of the paper that led to its creation have written another paper focusing on what happens next. I highly recommend having a read.

Anyone who has watched the news over the last few weeks will understand why there is a pressing need to improve the way healthcare organisations learn from harm and improve patient care. Since the Morecambe Bay Investigation report was published in March 2015, I’ve regularly been contacted by families affected by avoidable harm in healthcare and sadly, I still recognise many of the themes from that report. At the very time when families (and staff) need answers and support, often the current system only adds to their distress and inhibits learning.

Learning from deaths

These issues were highlighted powerfully by the CQC report published last year, ‘Learning, Accountability and Candour’, following the serious failure in care identified at Southern Health. In response, the government have recently introduced new national guidance, which every trust has been asked to follow from 1 April 2017. The new requirements cover the following areas:

  • Collecting specified information on deaths that were potentially avoidable and serious incidents and consider what lessons need to be learned on a regular basis.
  • Publishing information quarterly, in accordance with new regulations, so that patients and the public can see whether and where progress is being made.
  • Publishing evidence of learning and action‎ that is happening in response.
  • Identifying a board-level leader as patient safety director to take responsibility for this agenda and ensure it is prioritised and resourced within their organisation.
  • Following a standardised national framework for identifying potentially avoidable deaths, reviewing the care provided, and learning from mistakes

The big challenge now will be for local organisations to invest in the resources and systems needed to make sure the new guidance doesn’t become tick box, but rather drives deeper understanding and learning following avoidable harm in healthcare.

From litigation to resolution

Another significant announcement made this month was the news that NHS Litigation Authority (NHS LA) is now going to be rebranded NHS Resolution. The website for NHS Resolution has now gone live although it’s still clearly under development.

The website states:

“We know that claims are often pursued in search of an explanation or acknowledgement that something has gone wrong. Patients and healthcare staff do not want to find themselves in court proceedings, particularly when care is ongoing. Our experience of mediation and other forms of Alternative Dispute Resolution (ADR) is that a more effective solution can be found, when the court process is set aside, and the ambiguity and range of views which often exists can be properly explored.”

For me, it’s encouraging to see this shift of emphasis from ‘litigation’, to ‘resolution’. Patients and families affected by harm or the loss of a loved one following poor care, will overwhelmingly see establishing the truth and ensuring others aren’t harmed for similar reasons as the most important priority. In many cases, especially involving the loss of a loved one, financial compensation is so small it could only ever be seen as a token gesture, but in other cases, for example the where a baby is damaged at birth and requires lifelong care and support, financial compensation can rightly be significant.

In maternity care, litigation costs in the NHS have more than tripled in the last decade. In my experience, the way the legal system in the past has operated has not been helpful in creating the right conditions to encourage openness and learning and instead can encourage defensiveness. To a bereaved family, this becomes a prolonged battle for the truth that adds to their distress and acts as a barrier to the learning that is desperately needed to prevent further harm.

The government has committed to a range of measures designed to help address these, including a proposal for a new Rapid Resolution and Redress (RRR) scheme, modelled closely on similar scheme in Sweden. This is currently out for consultation. It is an important proposal and if done in the right way, the RRR scheme has the potential to play a vital role in improving safety in maternity services and helping to ensure families affected by the loss or serious harm of a baby are better supported in the future.

Restoring trust after harm

A common theme throughout all these recent initiatives is the need to improve the response to adverse events in healthcare. For NHS staff, this must include being supported through systems and leadership to deliver care in a safe way, and when things do go wrong, being supported to learn whilst being confident that the system will treat them fairly. This can only be achieved through a ‘just culture’ as opposed to a ‘no blame culture’, as discussed in this blog by Dr Roger Stedman

For patients, this must mean a more compassionate response, candour from the outset and full involvement with investigations and learning processes.

Murray Anderson-Wallace and Suzanne Shale have done some great work in this area and I highly recommend watching this presentation about their work.

Meanwhile at Datix

In my last blog I gave a brief update on progress relating to the new patient safety learning organisation we are busy setting up. We will launch the new organisation in September 2017 and over the next few months I’ll be writing much more about the type of organisation we are forming and how we will be working.

Last month I was lucky enough to travel to Bonn to attend the Second Annual Global Patient Safety Summit. Some more information about the event can be read here, but I thought it would good to finish this blog with one of the summary slides from day one of the event, which summed up a message for the whole field of patient safety perfectly:

“Continuous improvement of patient safety is only possible by systematically involving patients, their relatives and care givers as partners.”

These are great words and I’m pleased that this is a message that health ministers across the world are now hearing, but many people reading this blog will know just how far we have to go to close the gap between this aspiration and the reality on the ground.

In my view, patients, especially those with experience of being let down by healthcare, have a huge amount to offer, not just as voices to be listened to and ‘experiences to capture’ but by actually being involved in working with organisations and at a system level towards improvement.  There are some great examples of where this happens, but not nearly enough.

This is something we need to change.  


James Titcombe

James Titcombe OBE

Patient Safety Specialist

28 April 2017