At a clinical negligence conference in Manchester earlier this year, Denise Chaffer, who is the Director of Learning and Safety for NHS Resolution, said she wanted to work “to help the NHS become the largest learning organisation in the world”. No lack of ambition there, then.
Her focus was on prevention of maternity based claims, particularly child birth injuries, which is hardly surprising, as although they make up only 10% of all claims against the NHS, almost 50% of the compensation budget is taken up in meeting the cost of such claims. NHS Resolution is collecting data to enable it to do a “deep dive” (lovely use of jargon there) into the information to try to get to the heart of what are the main causes of claims. It is not always the fault of low staffing levels, lack of finance and poor resources.
The report is at https://bit.ly/2AuGCDH
There were three main strands.
First of all, many people feel that they have no option but to resort to the litigation process in order to find out what actually happened when an adverse incident occurs. Full and honest explanations at an early stage can often remove the need to take this step. The NHS does have a Duty of Candour, but this is not always honoured, or at least not as fully as it might be. This needs to be encouraged.
Secondly of course, it follows that if the explanation is that something DID go wrong due to negligence – and it is the negligence that is important as in such a vast system, things will go wrong without there being negligence and no-one’s “fault” -then an early resolution of the complaint or potential claim should be aimed for.
This is not always possible, but an early admission of liability and causation where appropriate would at least reassure potential claimants that they will eventually be compensated.
It may also open the way for interim payments to be utilised to help with the financial problems that can occur following accidents and injury.
The third element is learning from harm done so it does not happen again, or at least the incidences can be reduced. The NHS has a policy of GIRFT – Get It Right First Time- and again, whilst an admirable target, not always possible in real terms. Nevertheless, clinical negligence lawyers do see the same sort of negligent mistakes repeated and therefore having to be compensated, so surely it must be a priority to improve on this and reduce compensation payments?
NHS Resolution also carries the strap-line “Delivering fair resolution and learning from harm”. But does it? Can it? Will it actually happen in practice?
Whilst this may be a snappy strap line, the thinking behind this is vital for the NHS to improve on it’s patient safety record.
A brilliant and fascinating book – Black Box Thinking – written by Matthew Syed, takes an in-depth look at how organisations, in particular the Health Sector, must change their culture and learn from their mistakes. You could get it here:
If the NHS are to have any chance in succeeding in their goals to become a learning organisation and to learn from their mistakes, they must embrace a cultural change like never before.
Perhaps Denis Chaffer should have said that she wanted the NHS to be the ‘best’ learning organisation in the world, not the ‘largest’.
In the second part of this article we will explore the NHS’s plans in more detail. We will also look at ways we feel the NHS can save money when things do go wrong.