The National Health Service is suffering from a deficit of accountability and compassion for patients and their families when things go wrong, England’s Health Ombudsman has warned.
In a new report, ‘Broken trust: making patient safety more than just a promise’, the Ombudsman has said the NHS must do more to accept accountability and learn from mistakes, particularly when there is serious harm or, worse, loss of life.
When concerns are raised after such incidents they are too often met with a defensive attitude. This makes things even worse for a grieving family trying to get answers. It also places unnecessary pressures on staff, creating a barrier to learning and a gateway to making the same mistakes.
Despite significant progress made on patient safety in the last decade, ten years on from the Francis inquiry into failings in care in Mid-Staffordshire, we are still seeing too many preventable tragedies. The Parliamentary and Health Service Ombudsman (PHSO) considered over 400 serious health complaints from the last 3 years and found 22 cases of avoidable death.
The Ombudsman has called for urgent action from the Government to prioritise patient safety and protect families who search for understanding in the wake of a tragedy.
The report sets out recommendations to improve patient safety.
• better support for families affected by harm
• embedding cultures that promote honesty and learning from mistakes
• getting the right oversight and regulatory structures to prioritise patient safety
• and an evidence-based and long-term workforce strategy that has cross-party support.
Ombudsman Rob Behrens said:
“Mistakes are inevitable. But whenever my office rules that a patient died in avoidable circumstances, it means that incident was not adequately investigated or acknowledged by the Trust.
“Every time an NHS scandal hits the front pages, leaders promise never again. But the NHS seems unable to learn from its mistakes and we see the same repeated failings time and time again. Our report looks at the reasons for the continued failures to accept mistakes and take accountability for turning learning into action. We need to see significant improvements in culture and leadership. However, the NHS itself can only go so far in improving patient safety. One of the biggest threats to saving lives is a healthcare system at breaking point.
“The Government says patient safety is a priority but, if it means this, the NHS must be given the workforce capacity it needs. We need to see concerted and sustained action from Government to support NHS leaders to prioritise the safety of patients. Patient safety must be at the very top of the agenda.”
Responding to the report ‘Rory Deighton, director of the acute network at the NHS Confederation said: “This report will make sobering reading for health leaders whose teams are working in very challenging conditions to give their patients the best possible care. They will want to scrutinize these findings in detail to understand where improvements can be made and will be encouraged that the PHSO has recognised where considerable progress has been made already, as well as where further national support from government is needed.
“Whenever patient safety is compromised leaders and their teams carry this responsibility deeply, reflecting on what they could have done differently and where they could have been better supported. They tell us this is a key reason for stress and burnout on the frontline of the NHS and it is of no surprise that some have referred to their staff experiencing “moral injury” because of the situations they find themselves in.
“Our members understand that safety is the most important promise they can make to their patients and are committed to improving.
“The single most important thing the government can do to support patient safety is to set up the NHS to have the full complement of staff it needs to deliver healthcare at a time of rising ill health and demand for services, which is why the promised workforce strategy can’t come soon enough.”