The Ostrich Syndrome and Patient Safety

By John Tingle

Sadly, the NHS (National Health Service) in England is littered with examples of cases where individuals and organisations have seemingly buried their heads in the sand when patient safety errors have occurred. Attitudes that can be seen in past reports range from,’ it’s not my responsibility’, to procrastination, or passing the buck, assuming that another organisation is dealing with the matter or just simply delaying a response or even ignoring the situation completely.

Past cases

The Mid Staffordshire and Morecambe Bay patient safety crises where deaths and poor care occurred are prime examples of what can go wrong in this area. The Mid Staffordshire report identified a negative, engrained culture, which included a tolerance of poor standards and denial of concerns. The events at Morecambe Bay are also a salutary reminder of the failures in this area:

“Many of the reactions of maternity unit staff at this stage were shaped by denial that there was

a problem, their rejection of criticism of them that they felt was unjustified (and which, on occasion,

turned to hostility) and a strong group mentality amongst midwives characterised as ‘the musketeers’.p8

Two recent reports shine a bright light in this area of proper action taking and responses when patient safety errors are made.

The Paterson Inquiry Report

The Paterson scandal has been a story, which has raised significant public concerns about health care quality and patient safety. Reporters, Campbell and Topping, in the Guardian newspaper discuss the recently published Paterson inquiry report under the banner headline,

‘Report says hospitals displayed wilful blindness to damaging operations on hundreds of patients’:

“Paterson was free to perform harmful surgery on mainly female patients in NHS and private hospitals because of “a culture of avoidance and denial” in a “dysfunctional” healthcare system where there was “willful blindness” to his behaviour.”

The report discusses several issues including the complexity of our health care regulatory system and the difficulty in navigating it. The report makes several key recommendations, which include:

We recommend that the Government should ensure that the current system of regulation and the collaboration of the regulators serves patient safety as the top priority, given the ineffectiveness of the system identified in this Inquiry. (p221).

Patient safety alert system improvement

The UK charity, for patient safety and justice, AvMA (action against medical accidents) have recently published a highly critical report on patient safety alerts, implementation, monitoring and regulation in England. Serious problems are identified with the system of issuing patient safety alerts and monitoring compliance with them. The report reveals serious delays in NHS organisations and hospitals (Trusts) in implementing patient safety alerts. The report highlights key research findings, concerns and makes several recommendations. The report states that the CQC (Care Quality Commission), the independent regulator of health and social care in England, has no central database of non-compliance or action being taken about non-compliance with alerts. This information is being held at the local level:

“It is not clear whether any proactive action is taken to try to ensure trusts comply” (p23).

There are several other concerns, findings and recommendations. One recommendation made is that a more robust and proactive system of monitoring and regulating compliance with patient safety alerts in both primary, secondary and community sectors is required.


Both reports are to be welcomed, they are clear, well structured and contains crucial findings. They both address key NHS patient safety and health governance concerns. Common-sense recommendations are made in both reports, which will hopefully contribute to the development of an effective ingrained NHS 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.

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