A number of high-profile reports* in recent years have pointed to significant problems with the way healthcare organisations and the wider system sometimes respond to complaints and investigate and learn following patient safety incidents and unexpected patient deaths. These reports all point to some systemic problems including:
1) A lack of training and capacity for local organisations to undertake high quality investigations following adverse patient safety events.
2) A lack of trust by healthcare professionals in the processes of investigations, including wider systems of professional regulation, leading to a fear of blame.
3) A lack of support and inadequate involvement of patients and families in patient safety investigations, often leading to a further breakdown of trust.
In the vast majority of patient safety incidents or events, it is the systems, procedures, conditions, environment and constraints staff face that lead to patient safety problems.
However, if an organisation fails to support staff, or attributes inappropriate individual blame without proper consideration and understanding of the system factors involved, this can reinforce a culture of blame and lead to a lack of trust in the investigative processes.
Where this is the case, it is likely that staff will be fearful of being as open and transparent as they could be and this can greatly hinder an organisations ability to understand the underlying problems that contributed to what happened.
Since the publication of ‘Learning not blaming’in 2015, several changes have been introduced with the aim of tackling these issues and promoting a culture in the NHS that better supports safer healthcare. The new Healthcare Safety Investigations Branch (HSIB) is one the most important of these changes.
In May 2016, the Expert Advisory Group (EAG), which was established to provide advice on how HSIB should operate, recommended that the promotion of a ‘just culture’ should be a central principle in the operation of the new organisation.
“The Branch must promote the creation of a just safety culture: a shared set of values in which healthcare professionals trust the process of safety investigation and are assured that any actions, omissions or decisions that reflect the conduct of a reasonable person under the same circumstances will not be subject to inappropriate or punitive sanctions.”
This neatly describes the culture that we need to promote, foster and support in healthcare with trust running as golden thread.
For healthcare staff, trust in an investigative process will be dependent on whether staff involved in patient safety events are treated fairly and consistently such that there is confidence that normal human error will never result in punitive or disciplinary sanction or unwarranted blame. To achieve this, its crucial that staff carrying out such investigations are properly trained and supported. Resources such as the ‘just culture toolkit’ recently published by NHS Improvement can be invaluable.
One organisation that has done some inspiring work in this area is Mersey Care NHS Foundation Trust and this video about their journey of change is well worth watching.
For patients and their families involved in patient safety events, their trust in the healthcare organisation responsible for their care will understandably be broken. Rebuilding this trust will only be achieved if the healthcare organisation and staff involved are completely open and honest about what happened. Early candour is essential but it’s also crucial that patients and families are fully involved in any investigative processes that follow.
Empathetic and compassionate engagement and communication with patients and families is crucial as well as involving them fully in every stage of the investigation process, ensuring that their accounts of what happened are listened to, properly considered and any questions they have about what happened are explored and answered.
Achieving a culture that best supports all of these objectives isn’t easy; it means investing to ensure that staff have the right training, skills and tools to carry out investigations into adverse events such that ‘human error’ is always seen as the starting point of an investigation, not the end. Crucially, it also means that when trust between a healthcare organisation and a patient is broken, when something avoidable has gone wrong, the organisation can work to rebuild that trust in a culture that supports openness and candour. This can help ensure that the real problems that contributed to what happened are identified and acted on so that future patients can trust that they won’t be exposed to the same risks again.
- Francis R. Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office, 2013.
- Kirkup B. The Report of the Morecambe Bay Investigation. London: The Stationery Office, 2015
- December (2016) Learning, candour and accountability. A review of the way NHS trusts review and investigate the deaths of patients in England