“Shock”, “disappointment”, “disbelief”, “embarrassment” are just some of the many comments that accompanied the findings of Sir John O’Hara’s report; The Inquiry into Hyponatraemia-related Deaths.
The public, not only here but across the British Isles and beyond, have been made aware of unacceptable failings in the care of four (probably five) children and the cover ups to their avoidable deaths. People are genuinely concerned and wondering how safe health care is overall. This is a reasonable and rational reaction but I am confident that Sir John’s report will genuienly change, at least one pernicious aspect of health care, professional arrogance whether from practitioners or managers or both.
Structures, processes and outcomes define quality systems and any health inquiry normally focuses on structures and processes when an adverse outcome is identified. Since the outcome cannot be reversed the only thing an inquiry can do is make recommendations so that, where humanly possible, the same mistakes do not happen again. We are supposed to learn but sadly and too often what has been leaned in an inquiry fails to percolate into the cultures of organisations because it is ”culture”, to paraphrase; “ that eats structure and process for breakfast”.
It seems we have been here before and all too often. Similar reports include the failings in a wide range of health care settings. The Birmingham bone tumour service, cervical cancer screening, contaminated blood products and HIV, breast cancer screening failures and Mid-Staffordshire (The Francis Report). There were social care failing reports too; including the Beverly Allit affair and the Baby Peter (P) scandal. And then there are those specific reports which identified professional and managerial arrogance including; The Paediatric Heart Surgery in Bristol (the Kennedy Report), the Harold Shipman case and the Rodney Ledward Case.
The Bristol Royal Infirmary Inquiry the “Kennedy Report” was conducted between October 1998 and July 2001 and chaired by Professor Ian Kennedy. The Inquiry was divided into two phases. In Phase one the focus was on events in Bristol. Evidence from 577 witnesses including 238 parents was received in writing. Phase two was on the future and what to do with professionals who get too big for their boots. One hundred and eighty papers were submitted to seven seminars in which 150 participants from the NHS and the public and private sectors took part. It was highly critical of the way professional regulation was undertaken in some professions and it made a number of recommendations. It should have influenced and countered professional self-regulation and to a great extent it did. Self-regulation of professionals within organisations such as a Health Trust, it did not address and this is a theme that John O’Hara identifies time and again in his report.
And then we had the Francis Report into failings in Mid-Staffordshire. Robert Francis’s report on poor care at the Mid-Staffordshire Hospital Trust attempts to establish what went wrong and what needed to be done to ensure that such things do not happen again. His report makes dull bed-time reading but it is also a disturbing indictment of how bad basic hospital care can get when a systems-focus culture usurps basic care and compassion. Why did care staff keep drinking water out of reach of thirsty patients? One patient was found drinking water from her flower vase! Why did no one think that un-eaten food might not suggest satiety but rather an inability to feed oneself? And why did someone prescribed insulin not receive the drug and die in a diabetic coma?
What Francis found was that staff in this chaotic hospital simply didn’t care. Systems: the counting of widgets and writing of reports, took precedent over the dignity and the care of people. There was an air of arrogance that suggested that patients were lucky to be treated in that hospital by professionals as good as them. Managers, only concerned with targets, created a culture of fear which resulted in low staff morale. Clinical staff simply disengaged from managers who refused to give matters of clinical governance priority.
Something happened in Mid-Staffordshire that destroyed the professional caring culture that should exist implicitly within such an organisation. Culture again is key. Yet Francis did not pursue this sufficient robustly. Rather he pursued the systems approach recommending a set of “Fundamental Standards”. It is interesting that Francis recommends that his fundamental standards “should be limited to those matters that it is universally accepted should be avoided for individual patients who are accepted for treatment by a healthcare provider”.
And so we are here with another damning report, this time the lack of care of children in N. Ireland. It is professional arrogance that Sir John is particularly scathing of and which he is keen to remedy. Remedying it will not be easy but a statutory duty of candour, as proposed, would go some way to achieving this. Too concerned with their personal reputations; healthcare professionals and senior managers are guilty too often of putting themselves about patients and families. An attempt to get a statutory duty of candour implemented failed to be completed a few years back. When you mess up, no matter who you are, you need to own up and accept the consequences. Failure to do so is arrogance. Failure to own up is too expensive in terms of; lives lost in the future, time lost in direct patient care and money lost in holding expensive inquiries – the O’Hara report cost around £14 million. Let’s hope Sir John’s report proves to be money well spent.
I am a pharmacist in Belfast.
Living History 1968-74
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