NHS patient care and treatment errors: developing a learning culture.

By John Tingle

PACAC, the House of Commons, (Public Administration and Constitutional Affairs Committee) has just published its analysis of the PHSO’s, (Parliamentary and Health Service Ombudsman ) second report into the tragic death of Sam Morrish, a three year old child whose death from sepsis was found to have been avoidable. PACAC  is composed of MP’s (Members of Parliament) and its remit includes considering matters relating to the quality and standards of administration provided by civil service departments which includes the Department of Health. PACAC also examines the reports of the PHSO.

The PACAC report is very thorough and detailed and really gets to grips with the issues surrounding NHS (National Health Service) health adverse incident investigation. It addresses very clearly the current challenges and opportunities in this area and puts forward some major concerns which need to be fully addressed by the NHS before it can be said to have a listening and learning culture. It is clear from reading the report that the NHS has a very long way to go before it can be said to be even close to reaching its listening and learning culture attainment goal.

The PACAC report also identifies what could be regarded as some muddled thinking by the Department of Health on the concept of the ‘safe space’ in NHS investigations and identifies some important patient safety policy gaps.

The ’Safe Space’ Concept

The concept of the ‘safe space’ features very strongly in the report. The idea is that investigations by the new HSIB (Healthcare Safety Investigation Branch) will operate in a ‘safe space’ .To give the parties to the investigation, what is termed some ’psychological safety’ so that lessons can be learnt freely and a learning culture  can begin to flourish without fear of punitive action being taken against them. The report states that it is presently unclear how the HSIB , including its safe space investigations , will interact with existing bodies in the legislative landscape, such as the CQC (Care Quality Commission) or NHS Improvement to secure to secure improvements in the NHS investigatory processes.

The report  refers to four key terms that are now commonplace in discussions about the need to improve investigations in the NHS in England: ‘safe space,’ ‘just culture,’ ‘blame culture,’ and ‘learning culture.’ What is needed to achieve a  ‘just culture’ and the opportunities and challenges are  also discussed. A number of  important conclusions and recommendations are made in the report .

The concepts of ‘safe space,’ ‘just culture,’ ‘blame culture,’ and ‘learning culture’are very interesting. The analysis of them in the report is almost philosophical and jurisprudential in tone. What is worrying about this is that if the NHS gets too bogged down in defining terminology and abstract definitions then the battle to develop an ingrained patient safety culture will be lost. If we over confuse or over-engineer the discussion then we are going to obscure the communication  of key patient safety messages to all NHS staff at all service levels. There is I feel a real danger of this happening and it is one of the key reasons why the NHS has struggled over the years to develop an ingrained patient safety culture.


John Tingle

John Tingle is a regular contributor to the Bill of Health blog. I am a Lecturer in Law, Birmingham Law School, University of Birmingham, UK; and a Visiting Professor of Law, Loyola University Chicago, School of Law. I was a Visiting Scholar at Harvard Law School in November 2018 and formerly Associate Professor at Nottingham Law School, Nottingham Trent University in the UK. I have a fortnightly magazine column in the British Journal of Nursing where I focus on patient safety and the legal aspects of nursing and medicine. I have published over 500 articles and a number of leading texts in patient safety and nursing law. My current research interests are in global patient safety, policy and practice, particularly in African health care systems. My most recent publication is: "Global Patient-Safety Law Policy and Practice," edited by John Tingle, Clayton O'Neill, and Morgan Shimwell, Routledge 2018.

2 thoughts to “NHS patient care and treatment errors: developing a learning culture.”

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