Evidence submitted by the Medical Protection Society

Summary

1. When there are incidents of harm in healthcare, they are usually caused by many interconnected factors – both human errors and system failures.

2. Investigation of incidents needs to be sufficiently comprehensive to cover all relevant issues in order to be useful in preventing future incidents and to contribute to an open learning culture.

3. MPS is concerned that the Parliamentary and Health Service Ombudsman’s (PHSO) current investigations lack sufficient transparency and clinical expertise.

MPS experience

4. MPS advises members about complaints handling issues in both the primary care and secondary care sector, and has extensive experience of how the current complaints system works, as well as previous versions of the system. We provide educational materials and training on the prevention of complaints and effective handling of complaints to Trusts, individual GP practices and practice manager networks.

5. Patient safety is intrinsic to MPS and one of our aims is to work with healthcare professionals through education and risk management to prevent avoidable harm to patients. To meet this aim, we have developed a Clinical Risk Self Assessment (CRSA) for general practices. A CRSA is a systematic approach to identifying risks and developing practical solutions to ensure quality of practice, and preventing harm to patients.

Clinical failure

6. Incidents of harm in healthcare are rarely caused by a single factor. They are caused by an interaction between local conditions, human behaviours, social factors and organisational weaknesses.

7. Dr Reason created the “Swiss cheese” model[1] to explain human fallibility, which is made up of two approaches; the active (person) and the latent (system). The active failures are the unsafe acts committed by people who are in direct contact with the patient or system. These take a variety of forms: slips, lapses, mistakes and procedural violations. Latent failures arise from decisions made by management and others and these decisions have the potential for introducing failure into the system. For example, time pressures, understaffing, or inadequate training.

8. The “Swiss cheese” model illustrates the trajectory of an accident. The holes in the Swiss cheese represent the failures in the system’s defences that allow a hazard to pass through. So error is a combination of human and system failures. Everyone makes mistakes, so it is important that systems are robust to ensure that mistakes due to human fallibility are less likely.

Investigating clinical failure

9. Investigations into clinical failure must be sufficiently comprehensive and cover both the human/clinical elements and system issues if they are to provide a meaningful explanation as to what went wrong and to provide proposals to mitigate the risk of future events.

10. Investigations need to acknowledge that error is an inevitable part of human activity that is both unintentional but also not easily deterred. There needs to be appropriate expertise to assess the nature of any human error involved: whether it is an issue of skills or technical error; whether it is a failure to recognise patterns or apply an appropriate rule; or whether there was a lack of knowledge or information.

Reducing error

11. The best way of reducing error rates is to target the underlying system failures, rather than take action against individual members of staff. It is not the case that if people try hard enough, they will not make errors. Nor is it the case that punishing people when they make genuine unintended mistakes will mean they will make fewer of them in the future.

12. The culture in which doctors operate plays a significant part in reducing incidence of error. MPS has for a long time called for a culture of openness[2] in the NHS as our experience shows us that cultural and organisational failures play a significant role in clinical quality and medical error.

13. As the many reports and investigations over the last few years have shown, the readiness of doctors to carry out their professional responsibilities by raising concerns has often been clouded by fear of the potential for personal consequences. There is a need in the NHS for more to be done to tackle the reasons healthcare professionals and organisations are reluctant to be open with patients, as well as colleagues, when things go wrong.

14. We think that changing healthcare professionals’ reactions to incidents from one of fear into an eagerness to report, explain and learn from what happened can only happen through cultural change. Therefore, it is disappointing to see so much emphasis in the government’s response to the recent inquiries has been placed on creating new responsibilities and statutory obligations for professionals. Statute is a blunt and inappropriate instrument to address these cultural issues.

15. Whilst we understand the appeal of new laws and obligations on healthcare professionals, care must be taken so that these do not create a culture of fear or undermine the initiatives that can genuinely improve patient safety. Instead of new sanctions and duties, efforts should be focused on mentoring, training and supporting staff to communicate effectively and sensitively with patients when things go wrong.

The current complaints system and clinical incidents

16. The final part the NHS complaints process is the PHSO which often investigates the clinical aspects of failures in care arising from a complaint.

17. We find that the processes of the PHSO are slow and opaque. This is particularly the case in the decisions about redress payments, how they are arrived at, and the consideration of causation issues. Where clarification of these issues is sought, the response from the PHSO is frequently slow and inadequate, and gives the appearance of being defensive.

18. We also have concerns about the quality of the clinical advice relied on by the PHSO as part of her investigations. We are not aware of any quality assurance process the PHSO has in relation to clinical advisers.

19. This lack of transparency and clinical expertise would be problematic if the PHSO were to take greater role in clinical accident investigations.

About MPS

MPS is the world’s leading protection organisation for doctors, dentists and healthcare professionals. We protect and support the professional interests of more than 290,000 members around the world. Our benefits include access to indemnity, expert advice and peace of mind. Highly qualified advisers are on hand to talk through a question or concern at any time.

Our in-house experts assist with the wide range of legal and ethical problems that arise from professional practice. This includes clinical negligence claims, complaints, medical and dental council inquiries, legal and ethical dilemmas, disciplinary procedures, inquests and fatal accident inquiries.

Our philosophy is to support safe practice in medicine and dentistry by helping to avert problems in the first place. We do this by promoting risk management through our workshops, E-learning, clinical risk assessments, publications, conferences, lectures and presentations.

MPS is not an insurance company. All the benefits of membership of MPS are discretionary as set out in the Memorandum and Articles of Association.

For more information about MPS visit our website www.mps.org.uk