Those who follow the news would be forgiven for thinking that 2018 is the year of NHS scandals.
Sir Brian Langstaffe’s inquiry into infected blood products, from which 3,000 died and over 25,000 are believed to have been infected, is being heard as separate investigations into hospitals in Shrewsbury & Telford suggest that on evidence available so far, 40 babies have died unnecessarily and another 12 bereaved families have been contacted in case the deaths of their children arose from similar causes. Earlier this year more than 300 staff at Gosport Hospital have revealed how their attempts at whistleblowing led not to a review or internal change but rather recriminations, despite their belief that up to 456 patients may have died due to the use of unnecessary opiate painkillers.
Those with longer memories will recall the headlines surrounding Stafford Hospital where again the concerns of staff went unheeded.
We all make mistakes at work and those are more likely to occur in medicine, a hugely complex and demanding area where the challenges facing hard-working and dedicated clinicians comprise a daily hurdle. On the evidence available regarding the above four scandals, however, the primary issue has been whether mistakes were made, but it seems to me that those were then compounded by a second one – once problems arose were those addressed openly and swiftly? The NHS has been keen to boast its Duty of Candour, but the question now is whether that duty has been put into practice. These stories suggest not – instead, those who have tried to raise their own worries have been ignored at best or repressed at worst. A memorable example was that of Dr Stephen Bolsin whose concerns about paediatric cardiac surgery failure rates in Bristol in the 1990s led to his having to move to Australia since he then became unable to find work in the UK.
I believe the NHS is genuinely determined to root out poor practice, learn from mistakes and implement improvements. But this will only work if it is applied in real life at actual hospitals rather than simply being expressed as an ideal by politicians. No doctor, nurse or midwife will risk their own career if flagging up a scandal of the nature of Gosport or Bristol instead leads to the problem being hushed up. As a medical negligence solicitor I see similar problems every day, not necessarily on a Trust-wide basis but simply where an individual complaint or legal claim results in denials of any errors, no matter how stark the mistakes may have been. Figures from NHS Resolution reveal that where patients are forced to take the step of starting legal proceedings at court to obtain justice, four-fifths of them are successful. Couldn’t those errors have been admitted much sooner?
I do hope that the NHS does not become living proof of the old saying that those who forget history are condemned to repeat it.