The learning from mistakes league 2015
The government will shortly announce the results of its first annual “Learning From Mistakes League” table. The table is one part of a package of reforms designed to improve patient safety in the NHS, with the results produced by feedback from staff at each Trust as to how free they feel to speak out when things go wrong in their hospital. It is part of Health Secretary Jeremy Hunt’s plan to facilitate:
“One of the largest organisations in the world becoming the world’s largest learning organisation”.
This year’s survey is expected to announce that 120 out of 238 Trusts will score “outstanding” or “good”; just 50.4% of NHS Trusts in England. The remaining Trusts have scored “significant concerns” or “poor reporting culture”. It is thought that by publically naming poor performing Trusts within the league, priority will be given to acknowledging and learning from errors that have been made, which in turn should improve patient safety.
Action Against Medical Accidents (AvMA), a charity campaigning for patient safety and rights which recognises Clarke Willmott as Clinical Negligence specialists, has welcomed the changes but has said that the charity remains concerned over the:
“Woeful inconsistency and often inadequate quality of NHS investigations into serious incidents”.
Poor investigations and guarded reports are often reasons why client’s seek advice from Clinical Negligence specialists and commence legal proceedings against NHS Trusts. Many claimant’s say that had their complaint been properly investigated, and open and honest acknowledgements of error been given, then they would have been less inclined to proceed with a claim for compensation.
Jeremy Hunt has called for a “new era of openness” when it comes to patient safety and added the need to “unshackle ourselves from a quick-fix blame culture and acknowledge that sometimes bad mistakes can be made by good people”. He has said “it is a scandal that every week there are potentially 150 avoidable deaths in our hospitals and it is up to us all to make the need for whistleblowing and secrecy a thing of the past”.
The other reforms that make up the package including the “Learning From Mistakes League” include legal protection for anyone giving information following a mistake, credit given at NHS tribunals for those who are honest and apologise and a series of medical examiners who will review all deaths, and the setting up of an independent Healthcare Safety Investigation Branch (“HSIB”) as a forum for staff reporting concerns without having to be named on the report.
In addition, a ‘safe space’ will be created around medics who provide evidence that negligence may have occurred, to prevent evidence being used against them in court. Mr Hunt said:
“The results of such investigations will be shared with patients and families, who will therefore get to the truth of what happened much more quickly. However, unlike at present they will not normally be able to be used in litigation or disciplinary proceedings, for which the normal processes and rules will apply”.
Presumably the idea here is that the NHS can be open about errors in their internal investigation without fear of then incriminating themselves in the civil courts. However, it is difficult to see how this will work in practice. If an internal investigation has identified negligence, is it conscionable for the NHS to then defend a civil claim on the basis that that incriminating evidence is safeguarded? That cannot offer justice to a patient who wishes to bring a legal claim when they have been injured.