Scrutiny in the Spotlight – 28 November 2013 Accountability through listening – lessons learned from Mid Staffordshire Peter Watkin Jones Partner, Eversheds LLP Solicitor to the Mid Staffordshire NHS Foundation Trust Public Inquiry
A watershed moment • The Francis Reports – Putting the Patient first • The Berwick Report – A learning culture • The Clwyd & Hart Report • The Cavendish Report • Secretary of State for Health: “We need to hear the patient, seeing everything from their perspective, not the system‟s interests” 2
• The Keogh report: - Not confined to Stafford - No one operates in geographical, professional or academic • Government response to Francis: “While the remit of the Francis Inquiry was explicitly limited to the NHS , the Inquiry‟s recommendations resonate across the health and care system as a whole” • “Poor care can occur anywhere across the health and social care system” 3
4
5
The vulnerable patient in need of protection Extract from Trust investigation report 6
Extract from Trust investigation report 7
The public not speaking up • Some of them were so stroppy that you felt that if you did complain, that they could be spiteful to my Mum or they could ignore her a bit more. • There would have been a lot of little incidents that just made you feel uncomfortable and made us feel that we didn’t want to approach the staff. I did feel intimidated a lot of the time just by certain ones. • I think he felt as though he didn’t want to be a nuisance. Because of their attitude in the beginning when he first mentioned about the epidural, he felt as though it was a waste of time of saying that he was in pain. 8
The staff voice not heard There was not enough staff to deal with the type of patient that you needed to deal with, to provide everything that a patient would need. You were just skimming the surface and that is not how I was trained. A nurse 9
The staff voice not heard If you are in that environment for long enough, what happens is you either become immune to the sound of pain or you walk away. You cannot feel people’s pain, you cannot continue to want to do the best you possibly can when the system says no to you. A doctor who started in A&E in October 2007 10
The staff voice not heard • “We have got to go on doing our job because we have patients who need operations; we will have to mend and make do. Which is the Stafford way” . • Keogh – “organisations trapped in mediocrity” . • Disengagement – “ not my problem to solve” 11
Why was the professional voice silent? • Fiona Donaldson-Myles Study 2005 – Nurses felt reporting was worthwhile if the institution had subsequently taken action to prevent recurrence. • Collegiality - feel of betrayal - role reversal; “you would also stick up for me” • The employer not welcoming bad news and preferring it to be kept quiet • McGovern and Fisher 2010 – The 3 D‟s – Denial; not an exact science – Discounting; outside control – Distancing; mistakes inevitable • Bystander apathy - diffusion of responsibility means it‟s someone else‟s business • Government: “A keen sense of personal responsibility is an important factor in a professional‟s daily self -management and therefore to the continuing safety of patients” • “Safeguarding is everybody‟s business” 12
A negative non- PRESSURE listening culture? Targets FT status Jobs bullying REACTION Fear HABITUATION Low morale Denial Isolation External Disengagement assessments No openness BEHAVIOUR Uncaring Unwelcoming Tolerance 13
Those who could/ should have picked up the signs of the need to protect the public Local “regulation” • GPs • National Leaders – Department of Health – Commissioners • Quality regulators – Healthcare Commission/ Care Quality Commission – Monitor – Health & Safety Executive 14
Those who could/ should have picked up the signs of the need to protect the public Local “regulation” • The Government response to the Health Committee‟s 3 rd report – “After Francis: making a difference” “ Traditionally, the response of the Government and of the central organisations of the NHS to failure in care has been to acknowledge the individual failing and then emphasise the very large number of positive experiences and excellent outcomes that people experience every day in the NHS ” 15
Professional Regulators missing the signs • General Medical Council – 17 references • Nursing and Midwifery Council – 3 references • Professor Weir-Hughes – “The culture of isolation overrode the professional responsibility to report” • Royal College of Surgeons – “dangerous”; “dysfunctional” • Universities/ deaneries 16
A non-listening board An absence of clinical governance - staff • No systematic appraisal of staff • No culture of self analysis • Isolation and no peer review 17
A non-listening board Complaints and information • Risk register outdated • Lack of knowledge of untoward incidents • No effective learning from complaints • Action plans – a reliance on assurance • Patient and staff surveys not listened to • Whistleblowing failures 18
A non-listening executive • Lack of experience • Great self confidence • No effective clinical or professional voice on the board • Disengagement of medical staff from management 19
A non-listening board • Tolerance of poor practice – “The Stafford Way” • An unwillingness to refuse to perform the impossible or dangerous • Finding excuses for mortality statistics – “Boards use data simply for reassurance rather than the uncomfortable pursuit of improvement” (Keogh) 20
Non inquisitive non executives • Not holding executive to account • Wrongly categorising issues of risk to patients as “operational concerns of no strategic significance” – a “false distinction” • Reliance on assurances which were not checked or challenged • Closed culture • An acceptance that having systems was of itself sufficient 21
An isolated focus on finance • Focus on financial issues and targets • No insight into import of decisions on patient care • Policies based on an assumption that strong finances would equate to good quality care 22
Recommendations Categories 1-5 – all to achieve culture change 1. Openness, transparency and candour 2. Fundamental standards 3. Accurate, useful and relevant information 4. Compassionate, caring, committed nursing 5. Strong patient centred healthcare leadership 23
The Government response – some major headlines • 281 recommendations adopted in whole or in part • Organisational recommendations re merger of functions not adopted 24
Category 1 Openness, transparency & candour • Openness : enabling concerns and complaints to be raised freely and fearlessly, and questions to be answered fully and truthfully • Candour : informing patients where they have or may have been avoidably harmed by healthcare service whether or not asked • Transparency : making accurate and useful information about performance and outcomes available to staff, patients, public and regulators 25
Openness • Welcome complaints and concerns • Gagging clauses to be banned • Independent investigation of serious cases • Engaging complainants, staff • Real consideration by Trust Board • Information shared with commissioners, regulators, and public • Swift and effective action and remedies 26
Transparency • Honesty about information for public • Obligatory balance of information in quality accounts about failures as well as successes • Independent audit of quality accounts • Criminal offence of reckless or wilful false statements by Boards re compliance with fundamental standards • Criminal offence to give regulators misleading information deliberately • CQC to police these obligations 27
Candour • Statutory obligation – Individual professionals under a duty to inform the organisation – healthcare provider organisation under a duty to inform patient, whether or not asked (174) • Statutory sanction – Wilful obstruction of these duties should be a criminal offence – Deliberate deception of patients in performing duty should be a criminal offence 28
Category 1 Openness, transparency and candour – Government response • Statutory duty of candour to report mistakes that caused death or serious injury; possibly moderate harm (Dalton and Williams Consultation) from 2014 on every provider registered with CQC • Candour on care failings a pre-requisite to CQC registration • The CQC can prosecute providers in breach of the fundamental standards • Individual director can then be prosecuted if offence committed with their consent, connivance or through neglect • Contractual duty of candour – NHS Constitution (2013) 29
Openness, transparency and candour – Government response • Separate Criminal Offence (CPS) for providers to supply false or misleading information in complying with a legal obligation • “Controlling mind” applies again • Separate Criminal Offence where organisations or individuals are guilty of wilful or reckless neglect or mistreatment or patients • Trust should reimburse NHSLA compensation in whole/ part if not been open 30
Recommend
More recommend
