I support Mark McDonald’s submission that the Thirlwall recommendations will lead to more blame and suspicion in the NHS (17 October). We often hear of hospital scandals where trusts are intent on preserving their reputations, internal inquiries go nowhere, defensive clinical staff deflect blame on to others, non‑disclosure to patients of errors and “lessons learned” rhetoric that is quickly forgotten. There is also an industry of ambulance-chasing lawyers. None of this is conducive to a no-blame, honest, open culture in healthcare. The Thirlwall recommendations of more surveillance will make it worse.
There is an alternative. Most of my professional life as a hospital consultant, clinical director and deputy chief medical officer has been spent in New Zealand, whose publicly funded NHS is the same model as the UK’s – but with a major difference. In the 1970s, New Zealanders lost their right to sue for damages for medical accidents or injury through the public court system with the Accident Compensation Act. This got rid of the grievance culture and ambulance-chasers, and the system provided remedial care for any injury. In the 80s, after a huge scandal regarding medical investigations, the Cartwright inquiry ushered in the creation of the independent Health and Disability Commissioner (HDC) and overriding principles of patient safety, interests and consent.
All complaints – from patients, public and staff – about any health facility, organisation or practitioner go first to the office of the HDC for investigation. If the HDC deems it necessary, it goes to the various professional disciplinary bodies or to the Medical Council of New Zealand. HDC reports on complaints are publicly available.
In 2005, the government passed its “no fault, no blame” legislation. This brought in a duty to report “any risk of harm to the public from authorities responsible for patient safety”. This freed clinicians to engage with any compensation cases with openness. The system has its critics, but overall works well.
Dr Pamela S Melding
St Helens, Merseyside
Mark McDonald’s column is a breath of common sense. The Criminal Cases Review Commission is still considering Lucy Letby’s convictions, yet Lady Justice Kathryn Thirlwall has constructed a programme of reform on the assumption that the central conclusion of the case is beyond question. Meanwhile, barely enough time has passed for reflection on what would actually make neonatal units safer.
Thirlwall’s answer appears to be surveillance, suspicion and blame: cameras in cots, encouragement to report colleagues and an explicit retreat from the “no blame” culture developed precisely to make organisations safer.
But what makes a hospital safe? Is it a nurse wondering whether a colleague is about to report them, or a nurse confident enough to admit that they have made a mistake? Is it a doctor practising defensively, or one willing to report a near-miss before it becomes a tragedy?
Destroy candour and you destroy one of the most powerful tools of patient safety. A frightened workforce will hide mistakes, keep quiet about doubts and practise defensively. Patients will pay.
Mark Hanson
Hitchin, Hertfordshire
In March this year my daughter was born and died in the neonatal intensive care unit seven days later. I believe her death was preventable and one key mistake was made that resulted in her death. But I don’t blame the consultant who made (what I consider to be) the error. She was doing the best she could in a difficult situation.
What I find concerning is the follow-up from the trust’s management. They have bent over backwards to try to hide their tracks rather than discussing it openly and using it as an opportunity to learn and ensure other babies don’t suffer a similar fate. The response has been so heavy-handed that it’s an insight into the fear and blame culture doctors face, which I find so concerning. Mistakes are an opportunity to learn.
Name and address supplied
Mark McDonald makes many good points. But sadly he overlooks the role that patients and families play in their healthcare and safety. The NHS needs staff who can speak up without fear. But it also needs patients who are listened to, informed, supported and involved. Some of the most important safety signals come not from systems, but from the people experiencing care. If there is one lesson from the Lucy Letby case, it is that patients and families must be recognised as partners in identifying risk, seeking answers and driving improvement.
Paul Whiteing
CEO, Action Against Medical Accidents
