Reporting and investigations - a new way ahead for patient safety?

4 November 2014

Martin Bromiley

I've written about investigations in health care before but sadly, with a few notable exceptions, things haven't improved. We still waste vast sums of (our) NHS money and, even worse, we create false hope for harmed patients or bereaved relatives that ‘this won't happen again’.

Much has changed in the NHS with a renewed emphasis on learning, but we're moving deckchairs on the Titanic. When things don't get better despite renewed effort, it's a clue that the problem is either poorly diagnosed and/or we haven't got to the real root cause of the problem.

The cost of this failure is graphically shown in the quite extraordinary and tragic case of the Titcombe family. James Titcombe has tirelessly campaigned (among others) to ensure learning took place after the awful death of his newborn son, Joshua, and the newborns of other parents in the Morecombe area. His story has just been  and I'd urge you to find a quiet moment one evening to watch it.

On the horizon we have the good news of ‘’, the Duty of Candour passing through the legal process at the moment and forever associated with another child whose father, Will, has also campaigned tirelessly. While good news for all (yes, I do mean patients, clinicians and the system), there is the law of unintended consequences to consider.

Fundamentally, we need to make sure we’ve separated the learning and the blaming process.

Let me give you an example. You've made a big error. Yes, it was a systemic problem that led to the error, but it was still your name on the notes. There's no lasting harm and the patient didn't notice, but would you risk reporting the incident in case it came back to haunt you, used in disciplinary or even judicial proceedings? Then you have to be open with the family. What do you say, either verbally or in writing, knowing that your words, just trying to be honest, could be used against you? I'm guessing you'd tell the truth, but maybe just a little economically? ‘Don't give any detail, just in case’ was how one professional put it to me. Where's the opportunity to learn then?

We've achieved such high standards of reporting in aviation by considering these barriers. I quote from one UK airline ops manual: ‘Human error, freely admitted will not result in disciplinary action, although the company retain the right to discipline in the event of gross negligence or deliberate acts’. The reports go to a specialist team who remove any names before it’s included in the monthly safety stats and reports, which are shared openly across the airline.

It's worth saying that while lower level investigations in aviation are done at a company level, the more serious events are investigated independently. This is another way to separate the potential for learning and blaming.

In the UK the Air Accident Investigation Branch (AAIB) is the independent body and it's worth noting that interviews, recordings, notes and reports done or used are not admissible as evidence in court, as recommended by international protocol. This includes the final AAIB report which is published anonymously and publicly in full, yet not used in subsequent legal action. The AAIB are clear that their role is learning, not blaming. Of course the police usually investigate accidents as well, but those involved can speak freely with the AAIB investigators to enable learning, the thing that I firmly believe is most important.

Blaming lasts a lifetime, systemic learning can last for much longer.

So should there be an NHS Medical Accident Investigation Branch? Two leading thinkers now say yes. Professor Charles Vincent and his colleague Carl Macrae have just  on this and it's a great read.

Speaking to many patient campaigners, clinicians, politicians and journalists, it's clear that there is much disagreement about how we move forward. Let me offer one question though: what do we want to achieve by investigating?

In my own experience, what the majority of harmed patients and relatives want most of all is for it never to happen again. The desire for blame often only comes after the system fails to be honest and investigate properly.

A true ‘just culture’ will aim to learn, and blame only if appropriate. But the experience of other safety critical industries would suggest that learning and blaming need very different mechanisms otherwise one will always compromise the other.

The good news is that the Clinical Human Factors Group, in conjunction with other major players, is helping get a group of experts together and thrash out the issues to achieve some agreement before national NHS bodies go down a route to sustain the status quo.

Which would be the biggest disaster of all.

Martin is a pilot and the founder and current Chair of the Clinical Human Factors Group,

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