Are Health Trusts learning from their mistakes?

Posted 11/03/2016 By: Amanda Cavanagh

Health trusts in England have been ranked by their ability to learn from mistakes, as part of several changes designed to improve patient safety. The “learning from mistakes league” rates 120 trusts outstanding or good, 78 with “significant concerns” and 32 with a “poor reporting culture”.It uses feedback from staff on their freedom to speak when things go wrong.

Other measures include legal protection for staff who admit mistakes, although it is not explained what is meant by legal protection, and new medical examiners to review deaths.

‘Blame culture’

Health Secretary Jeremy Hunt, is hosting the second of a two day “global patient safety summit” in London today.He has said that the changes were a step towards a “new era of openness” and that health services must “unshackle ourselves from a quick-fix blame culture and acknowledge that sometimes bad mistakes can be made by good people”.

The changes announced by Mr Hunt include:

• a new independent Healthcare Safety Investigation Branch where staff can report concerns without bringing them into conflict with their employer or attaching their names to reports of wrongdoing
• legal protection for anyone giving information to the investigation branch following a hospital mistake
• credit given at professional tribunals to NHS staff who are “honest about mistakes and apologise”
• from April 2018, expert medical examiners will review all deaths and confirm the cause

Peter Walsh, chief executive of patient safety charity Action Against Medical Accidents, welcomed the initiatives but said he remained concerned about the “woeful inconsistency and often inadequate quality of NHS investigations into serious incidents” and has said that there was “nothing” in Mr Hunt’s announcement to reassure his organisation that urgent action would be taken to address the quality of local investigations.

James Titcombe, whose son Joshua died after failings in care, said the measures were “major steps that will help move the NHS towards the kind of true learning culture that other high-risk industries take for granted”.

Amanda Cavanagh, Trainee Legal Executive in the Clinical Negligence team at Ashtons Legal, comments: “I welcome any scheme which has the ability to reduce the length of litigation and costs for both the Claimants and the NHS.Far too often lawyers are blamed by the NHS for the rising cost of compensation payments.However, if as is proposed, mistakes are admitted by clinicians, it should follow that early admissions of liability are made in clinical negligence claims thereby saving costs in the long run for the NHS”.