It’s often said that the NHS isn’t an organisation but a network of organisations – a system, if you like. There are of course good and bad parts in any system, and in this and my next blog I want to explore the extremes of both – often at the same geographical location and, ironically, often involving the same people.

There’s been a real shift in thinking in healthcare in the last few years. A focus on clinical professionalism being about technical perfection despite 'the system', has been replaced with a more realistic view: that whilst clinicians need excellent knowledge, that same knowledge hasn’t stopped the system from killing people. We now need to understand why things go wrong, be open and learn from disaster, and embrace safety sciences, system improvement methodology and human factors.

Although full of good intentions, that shift has sometimes rushed and ignored the science. Even worse, it has ignored the bigger picture of what we’re trying to achieve as one system, as clinicians and patients.

I’ll start in 1990. Will Powell’s son, Robbie, died after a failure to diagnose correctly. Sadly the story isn’t that simple – in fact he died after a ‘catalogue of failures and missed opportunities’ to quote one health minister, but that doesn’t really explain the real tragedy and circumstances.

Will has shown incredible strength of character and passion, but most of all determination and tenacity in trying to achieve justice for his son. Robbie may have died as a result of a failure to diagnose correctly but what followed was, if it’s possible, as bad: an alleged series of attempts to cover up, hide and avoid responsibility, including alleged criminal acts. It should be no surprise that Will has also campaigned tirelessly for a ‘legal duty of candour’; a legal requirement to be open and honest with patients when things go wrong.

As a result of Will’s work the idea of a legal duty of candour has been raised again and again, and most recently was a feature of the Francis and Berwick reviews. In the last few years we’ve seen a growing understanding of not just how to respond better to disaster, but also how we might stop these disasters being as common. So surely everyone would now agree that we should be open and transparent when things go wrong?

At the end of 2013 I visited a hospital in the south of England to speak to a group of registrars about human factors, safety and efficiency. I arrived while one of them was talking to her group of peers about ‘errors and candour’. As I sat I was stunned and delighted, in equal measure, by the depth of understanding of human factors, and also by the complete acceptance of the need to be open and honest with patients. There was intelligent debate about some of the issues and ‘technicalities’, but I was left with the impression that here was a group of registrars who not only are the future, but can also really make a difference. Morally they knew exactly what openness and transparency meant and that they are the same, whether patient or clinician.

So things are getting better?

Move forward to January 2014.

This month the BBC reported on a Coroners Inquest into the death of a teenager, Victoria Harrison. Victoria died at Kettering Hospital after a series of errors which the hospital admitted to at the Inquest. The hospital had carried out a Serious Untoward Incident review and, based on what was reported from the Inquest, it’s clear that poor situational awareness on a number of levels and at different stages, as well as poor communication and handover – all human factors related issues – were key.

So what does the full SUI actually say? No one outside the hospital knows because, despite a Freedom of Information Act request, the hospital has refused to make it public because it might put staff ‘under additional stress and pressure’.

On the one hand I want to congratulate the hospital for thinking of its staff. The ‘second victim’ bears a terrible burden, and deserves to be supported. But how will keeping the report secret help them deal with this burden?

The hospital offered a very legalistically worded reason and I’m not sure whether the motive is genuine or misguided by lawyers. At best it seems like a paternalistic, well-intentioned idea that is stunningly at odds with everything the whole of healthcare needs to achieve.

Actually it’s completely and utterly incomprehensible. ‘We had a death, a young life was lost, the underlying issues were potentially common in so many incidents, but we’re not going to allow anyone to learn from this outside of Kettering.’ And if there’s one thing we know about SUIs, it’s that the causes are usually sadly predictable and common thoughout healthcare.

Truth and reconciliation?

I have no doubt that those involved in my late wife’s death have found my attempts to publicise her ‘incident’ uncomfortable. I’ve always aimed to cause no additional harm, but I accept that it must be dreadfully uncomfortable for them at times. However I hope that they can be comforted, as I and my children are, that lives have been saved as a direct result of that work. It gives, if you like, a meaning to something so meaningless. And young death is often meaningless.

Surely saving further loss is the best outcome from unintended harm and death? Long-term change requires the whole system to grasp the lessons.

I fear that not only will Victoria Harrison’s family and friends feel denied that opportunity, but I’m sure that the staff involved have been denied their opportunity to really see things change as a result. Local improvement is nice, but so much more could be learnt.

I can only quote from Victoria Harrison’s mother who said this: ‘...I forgive the hospital, mistakes are made...I think it (the report) should be out in the public domain, but obviously without names... It will make people more aware, if they know which mistakes were made’.

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

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