Learning from mistakes and the art of burying bad news
At a time of much change in the world, it is perhaps unsurprising that the news media do not always pick up on what may prove to be important announcements. Recently there has been much focus on the Department Of Health clinical negligence cost consultation, which purports to seek to cut the fees being paid to “unscrupulous solicitors” representing those who have been injured by the failings of the medical profession. What appears to have gone unnoticed and unreported are the findings of Public and Constitutional Affairs Committee of the House of Commons, published in their seventh report on 17th January 2017, entitled:
“Will the NHS never learn? Follow-up to PHSO report ‘Learning from Mistakes’ on the NHS in England”
This cross party group of senior MPs reached a damning conclusion, having reviewed the recent past performance and proposals for future improvement of the NHS. Whilst the cost consultation pays lip service to the concept of learning from mistakes, in practice, the NHS fails to adopt practices which enable it to avoid repeating the same mistakes time after time. Life threatening, life ending and disabling conditions continue to occur in frighteningly repetitive circumstances as a result of treatment or lack of treatment that is wholly unacceptable to the medical profession.
As the committee noted:
“It is clear from the evidence reviewed during the course of this inquiry that the investigative processes in the health service in England remain obscure and difficult to navigate for patients and families. As a result, patients and families are excluded by the system, which must become open and learning-focused if investigations are to lead to positive changes in the system. Families and patients should, as a matter of course, be included in investigations and should feel confident that lessons will be learned as a result of clinical incidents.”
Lessons are not being learned, avoidable mistakes continue to happen and the Committee found the proposals to reform the situation totally lacking in credibility. This is indeed worrying, as one of the main arguments for reducing the involvement of solicitors in the sphere of medical mismanagement is the assertion that the NHS has in place the means to rectify problems itself. Reducing the ability to intervene of those whose task is to identify and cast a light on unacceptable failures in treatment before proper alternative procedures are in place can only lead the continuation of the current unacceptable situation.
Since an improvement in care for patients and a responsible attitude to the families of those injured or killed due to medical failings would appear to be a goal common to all, it is essential that a failure to achieve those goals is properly reported and not lost amongst the headline grabbing stories the media find more newsworthy.