Written evidence from Scott Morrish (LFM 20)
Public Administration and Constitutional Affairs Committee
Follow up to the PHSO report: Learning from Mistakes inquiry
1 - Introduction. My name is Scott Morrish. ‘Learning From Mistakes’ is about the NHS’s failure to investigate and understand the sudden, unexpected and avoidable death of my son, Sam Morrish, on 23rd December 2010. I was a member of the advisory group for the Healthcare Safety Investigation Branch (The HSIB). I have no relevant expertise beyond my experience as a patient. I want to add to, and expand upon, the oral evidence I gave to the Public Administration and Constitutional Affairs Committee (PACAC) on Tuesday 8th November. Whilst ‘Learning From Mistakes’ focuses on the worst of experiences, I have also experienced the very best of the NHS, both before and after Sam’s death. Whilst striving for insight and objectivity, I remain mindful of my inevitable bias.
2 - Key points.
3 - Test of character. Healthcare should epitomise and embody compassion for all involved. But to consistently deliver compassionate care requires a ‘just culture’, ‘psychological safety’ and a ‘growth mindset’ which in turn require the right structures and processes. I do not think we have them yet. If we want to make rapid, informed and effective progress in terms of patient-safety and staff-welfare - we can: we simply have to choose to do so. The time and opportunity to address these fundamental issues is now. This submission is written with these beliefs, hopes and expectations in mind.
4 - Dot-to-dot. A superficial analysis of Sam’s case might conclude that the problems were simply local failures of competence, which were then compounded by more local failures of investigative and complaints processes. Perhaps a more insightful analysis might suggest a lack of focus on learning; a blurring of boundaries that should separate line-management from complaints handling; or they may reveal a vacuum left by poor governance, weak leadership and - alternately - misguided and ineffective regulation. ‘Learning From Mistakes’ reveals some of this but, remembering my bias, I think it falls short of joining the dots together and fully explaining how this was allowed to happen.
5 - Window into ‘the whole system’. Sam’s case offers a rare - and now publicly documented - window into the (too often) opaque and (too often) dysfunctional inner-workings of ‘the whole system’. It allows those who want to see, to look deep into the NHS’s culture. It reveals significant differences between the rhetoric of ‘healthcare as set out in policies, pledges and promises’ and the reality of ‘healthcare as experienced and evidenced’. Sam’s case reveals that when things go terribly wrong - irrespective of guidelines - the combined effects of the current culture, structures and processes do not reliably deliver safe, compassionate or ‘just’ responses for patients or staff.
6 - Albatross. Individuals working in such cultures, may strive to be compassionate, but cannot always compensate for the lack of compassion that structures and processes impose upon them. Thus good people can end up behaving in ways that seem cruel and heartless, often whilst feeling and being isolated, powerless and vulnerable. This generates anxiety and resentment. The consequences include a corrosion of trust and respect, and can lead to defensiveness, demotivation and disengagement. The effects hang heavily - like an albatross - around the NHS’s neck.
7 - Don’t mention the culture! I am often advised not to talk about the NHS’s problems in terms of ‘culture’. There is often uncertainty about what it really means. Some think it is too big, abstract or difficult to change. Others embrace its ambiguity to side-step and diffuse both responsibility and accountability. Unfortunately this allows everyone to behave as if culture is beyond our understanding or control. This is revealing and dangerous.
8 - So… let’s talk about culture. By ‘culture’ I simply mean “the way we do things around here”. It is a short-hand for capturing the accumulated effects of behaviour, attitudes and the ‘accepted norms’ that characterise real-time responses to situations, as opposed to the responses that might be expected by the authors of guidelines or policies. Culture is not vague, and we ignore it at our peril. The sun can warm us on a winter’s day but burn us in mid-summer. In the same way, the cultures we work in either encourage or discourage openness and honesty; which in turn builds or destroys trust and respect, and affects whether compassion is able to flourish, or left to wither.
9 - Who’s in charge? But we do not have to let ourselves become hostages of the wrong kind of culture. Culture influences us but only has power over us - if we allow it to. We shape culture, and in turn, it shapes our attitudes and behaviour. The more we understand culture - the better our ability to shape and take control of it, rather than allowing it to cause harm.
10 - Vision. This requires enlightened leadership, good governance, and the right kind of regulation. One of the problems at the moment is the endless diffusion and evasion of responsibility. It is not the fault of the culture: it is a procedural and structural failing, for which leaders, policy makers and regulators bear responsibility. Academics wryly note that ‘culture eats strategy for breakfast’, but it is not obvious that policy makers, regulators, or NHS leaders have fully understood this truth, or its significance, yet...
11 - Aloof. After Sam died, the NHS behaved as if it didn’t expect or want to be challenged. First, having effectively marked its own homework, it offered itself ‘assurances’ that it had done everything that could have been done, concluding that Sam could not have lived. During those early weeks we were shown kindness and treated sympathetically. But sympathy does not keep people safe, or constitute a basis for trust. Understanding the differences between ’assurances’ and ‘evidence’ is vital. Failing to do so is fraught with dangers. One example is the scope it leaves for regulators, leaders, organisations and individuals to delude themselves that they know, or understand, what has really happened, or what really matters. The delusion ‘assurances’ offer may be more comfortable than ‘evidence’ - but they suck the life out of our collective abilities to understand; to learn or improve; to be honest and open; and also - if necessary - to hold individuals or organisations accountable. It is little more than legitimised ignorance.
12 - Ownership (without responsibility). With time the NHS behaved increasingly as if it ‘owned Sam’s death’ and as if I had no need, reason or right to be able to understand it myself. As my frustration grew at their inability and unwillingness to answer simple questions, it started sheltering behind its own ‘assurances’ - even when those assurances were contradicted or undermined by ‘evidence’. It blamed ‘systems’ and ‘processes’, for which - to this day - no one takes responsibility. Thereafter, for years, although individuals have shown as kindness and compassion, the NHS as a whole became closed and defensive. It tried to prop up a delusional impression of ‘robust systems and processes’ that clearly had no effective checks or balances, nor any interest in them. It apparently failed to recognise or understand the danger and fragility that such behaviour builds into our health service.
13 - Power needs checks, and balance. The NHS’s hierarchy is steep and power resides at the top. Leadership that enjoys power without effective checks and balances can simultaneously breed ‘complacency for management’ and ‘anxiety for almost everyone else’. These are the perfect conditions for inertia and the preservation of the status-quo, but not for learning or improvement. The problems are both procedural (processes) and structural (leadership and regulation) but manifest themselves in the attitudes and behaviour of individuals and organisations: i.e. culture.
14 - ‘Growth mindset’. Our experience is not unique and fits patterns experienced by others, some of which are documented, many of which are not. What the pattern reveals is not the result of a conspiracy - although it can feel like one - but a fear-filled and ‘fixed mindset’ that is fragile and judgemental, rather than a ’growth mindset’ (Carol Dweck) that is adaptable, resilient and capable of compassion and problem solving. This may seem like a minor point, but in fact, I think, cuts to the heart of the NHS’s problems.
15 - Culture, and reducing avoidable harm. The NHS cannot reduce avoidable deaths if unwilling or unable to recognise them. There should be an expectation of learning and improvement. Investigations should be welcomed rather than feared, and collecting multiple perspectives of adverse events should be the base-line for normal practice because it is recognised as the only way to optimise understanding and knowledge. But that requires ‘Psychological Safety’ (Amy Edmonson) and a ‘Growth Mindset’, both of which are essential if we want to optimise engagement, learning and improvement - especially when things go wrong. In Sam’s case, there was not much evidence of ‘psychological safety’ or a ‘growth mindset’. At times it is easy to decry the NHS’s culture. But failing to understand its underlying problems reduces our chances of addressing them to luck rather than judgement. Indeed it may lead us, despite good intentions, to making matters worse. The complaints system offers a good example of this.
16 - The problem with complaints… Some talk of complaints as gold dust. I disagree. Perhaps learning and insight could be described as gold-dust - but complaints processes aren’t good at generating either. Complaints are better understood as ‘alarm bells’. To make matters worse, current complaints processes are divisive. They seem to legitimise defensive behaviour on the part of the NHS, allowing it to perceive people like me as problems that need to be managed, loosing sight of the fact that I was simply an ordinary, grieving, vulnerable patient. Being treated like a problem sets the wrong tone.
17 - Judgement is not insight. Complaints processes should never be thought of as a substitute for ‘safety’ or ‘learning’ investigations. Their goal is not insight, learning or improvement: it is simply ‘judgement’ based on the differences between ‘work as imagined’ (guidelines, standards etc.) and ‘work as experienced’. Judgements made with little understanding of the complexity of everyday work generate wariness, and indeed weariness - especially for more junior staff. Without offering excuses, it is easy to understand how they lead to defensiveness.
18 - The duty of care… and common sense. When things go wrong - as we know they will sometimes - there should be an imperative to simultaneously [1] support and care for everyone affected or involved, and [2] to establish what happened, how and why in order reduce the likelihood of recurrence. How else can the professional or moral ‘duty of care’ to patients or staff can be fulfilled?
19 - Honesty as a basis for trust. Within months of Sam’s death, with a growing list of unanswered questions, I simply needed honesty, first in order to be able to try to understand Sam’s death, and second to be able to re-establish a basis for trust. The very last thing I needed was a complaints form - especially one that told me I had to complain within 6 months!
20 - Compassionate? Humane? A compassionate health service would not force patients to become complainants, or staff to become whistle-blowers - especially in the instance of a sudden and unexpected death of a child. It places an inhumane burden and responsibility on the shoulders of complainants - often at times of intense trauma and extreme vulnerability. Yet I - like many others - was left with no choice. I did not want to complain, and should not have had to, but colluding - by doing nothing - was unthinkable. It would have meant no chance of personal understanding; a vanishingly low probability of learning or improvement for the NHS; and no solid basis for trust in the future. I felt forced as I was forced to complain. It may be inconvenient, but ‘compassion’ is not a box that can be ticked to prove compliance within prescribed timeframes.
21 - Russian roulette. Reliance upon complaints systems - especially ineffective and unaccountable ones - is akin to playing Russian roulette with the lives of patients and the welfare of staff. It smacks of complacency and indifference. It is wildly inappropriate in healthcare which is by nature often complex, uncertain, high pressure, multidisciplinary, and regularly handling life-or-death situations. Nobody is served well by leaving learning or accountability to the vagaries of idiosyncratic complaints systems. It is high risk, random, reckless.
23 - More than incompetence. At the start of ‘Learning From Mistakes’ I asked the Public Health Service Ombudsman (PHSO) to establish whether the NHS’s failure to properly investigate and understand Sam’s sudden and unexpected death was the result of a cover-up or incompetence? Or, if neither, what was it? The PHSO concluded that it was incompetence. But that conclusion does not capture the whole story. Incompetence was certainly a factor, but shockingly, was tolerated for years during which neither the NHS’s leaders nor its regulators seemed to take any action. Non-compliance and ineptitude appeared to have no timely, meaningful or effective consequences.
24 - Brutal. Forcing patients or staff to choose between collusion or complaint is cruel, avoidable, and wrong. It also puts the system into a defensive mode that is more a kin to crisis management than objective or open minded investigation. ‘Learning From Mistakes’ documents one example of the consequences - a bunker mentality - where self-justification, finger-pointing, and the combined effects of wilful-blindness and a conspiracy of silence fog the air. The purpose of a safety investigation would be to clear that fog.
25 - Achilles Heel. Far from helping - the complaints system and its processes reinforce ‘silos’ wherever they exist (everywhere it seems), and drives wedges between patients and staff; organisations; departments; levels of hierarchy; and even individuals within teams. You can see the same forces at play between regulators, and government departments. Current structures and processes - instead of helping - raise the stakes by increasing the pressure and risk for everyone involved and affected. The goal is not learning. It is survival.
26 - Insight rather than judgement. ‘Learning From Mistakes’ represents something of a departure from normal PHSO practice. The normal goal is to reach a ‘robust adjudication’ based on comparing ‘what was recorded to have happened’ with ‘what was supposed to happen’. In this instance, at my request, they went further. As a result they have managed to capture some of the detail - although not all - about how and why the NHS proved unable and unwilling to properly investigate or understand Sam’s death. By interviewing those involved and gathering multiple perspectives they have been able to capture evidence and insight. As such it is a significantly improved report that should be welcomed.
27 - Handle blame with care. Whilst I identify blame as part of the problem with the current NHS culture, I want to stress that I fundamentally disagree with the notion of a ‘no blame culture’. Blame is inescapable. We cannot banish it or wish it away. What we do with blame is what matters, and that is - I think - where many of the current cultural problems originate. Currently, inept procedures, governance and regulation allow blame to be used and abused in a number of ways that increases risk for patients. Blame should not be synonymous with shame. Yet too often it is - especially when tragic situations are only seen through the lens of complaints systems that are focused on judgement, as opposed to learning or insight.
28 - Think before shaming. Failing to properly understand or handle blame increases anxiety and fear for staff and consequently reduces openness, collaboration, understanding, learning, innovation and improvement. Compassionate and hardworking staff can end up feeling isolated, disempowered and - eventually - disengaged. Patients that have had the misfortune to suffer harm - are offered the complaints system. A ‘just culture’ would handle blame very differently. To make that possible however, we need a very different kind of governance and regulation.
29 - “People do what you inspect, not what you expect.” (Louis V. Gerstner). When giving evidence I expressed my doubt that we could regulate ourselves out of this situation. That is not to suggest for one moment that regulation does not have a vital role to play: I doubt that we have the right kind of regulation at the moment. Sam’s case confirms - clearly in my view - that you get what you regulate for!
30 - Do no harm… In the event of serious adverse clinical outcomes - especially the sudden and unexpected death of a child - failing to undertake prompt, objective and inclusive investigations in search of comprehensive explanations and understanding about what happened, how and why, should be considered both unthinkable and wholly unacceptable by everyone. So it is chilling to note that without our persistent challenge - there would have been very little learning after Sam’s avoidable death: there was no expectation of, or appetite for, learning. Without an expectation and verification of learning - how can we hope to reduce avoidable harm?
31 - Looking at the evidence, is it reasonable to ask… How regulators that allow staff to de-list themselves and thereby evade scrutiny (GMC), or take 5 or 6 years to suspend staff whose incompetence contributed to an avoidable death (NMC) keep patients safe? And what is the point of responsible officers who preside over people and processes (NHSE), but don’t take responsibility for anything? Or of regulators that have nothing to say about the lack of meaningful or effective governance of failed investigations (HCPC)? And do regulators that call for culture change without recognising or accepting their own role and responsibility for shaping the very culture that they also criticise - really possess the necessary insight. And will anyone notice that the Child Death Overview Process (DfE) is a lottery with no checks or balances or means of evaluation in terms of effectiveness, or of accountability?
32 - Trust and verify. We have to be able to trust the NHS, but trust rests on certain criteria that the NHS has to meet first. If a child dies suddenly and unexpectedly, and investigations leave reasonable and relevant questions unanswered, forcing a family first to complain, and then to turn to the media, then clearly there will still be serious work to do. Monitoring the nature (qualitative) and numbers (quantitive) of complaints received in the future, alongside compliance with recommendations for remedy or improvement, will allow verification of whether we have the right culture and regulation… or not.
33 - Regulate for safety, compassion, fairness. We need a different kind of regulation, forged in pursuit of a ‘just culture’, that rewards compliance but which also punishes non-compliance. Leaders and regulators need to recognise that they share significant responsibility for the state of the culture that we currently have. If they can grasp that nettle then - perhaps - they can play a more constructive role for all of our futures. If not, they should be scrapped and replaced.
34 - Leadership. Making chief executives and their boards accountable for the ‘quality’ (rather than just quantity or timeliness) of their incident investigations and complaints handling would serve two purposes that are not reliably met at the moment. First it would focus their minds on ensuring that ‘processes’ were good, effective and properly implemented. Secondly it would mean that they would hear what was really happening in their organisation, as opposed to only hearing what others may choose to tell them. It would not appeal to, or serve their ‘own interests’ to leave learning in the hands of people who were ‘not up to the job’, and thereby serve everybody else interests - patients and staff - much better.
35 - A Just Culture. There should be clarity (for everyone) about when punishment is, or is not, appropriate, and who decides. These are the basics of a just culture. The objective is not to prioritise safety over accountability, or vice versa. The goal is to clearly, consistently and fairly balance both. Like good soil, a just culture needs to be cultivated and nurtured with care: it can be ruined very quickly. Accordingly regulators need to be constructively engaged in shaping the culture, alongside frontline staff, patients and policy makers - amongst other. All structures and processes need to be designed and aligned to genuinely balance safety and accountability. Safety depends in part upon fair, clear and consistent application of accountability. When people know that learning rather than shame is the purpose of investigation - it makes openness, even when still difficult, easier. With time - that becomes the cultural expectation - at which point the culture has changed.
36 - Safety Investigations. When something has gone wrong, the objective of ‘safety’ or ‘learning’ investigations is purely to establish and understand what happened, how and why in order to order to facilitate learning and enable improvement to safeguard the interests of future patients and staff. To do this they gather as many perspectives as necessary to ensure both investigative resilience and the integrity of its findings and recommendations. They are not alternatives or substitutes for any other kind of investigation. They stand alone and serve the vital functions of expanding knowledge and expertise, which we overlook at our peril.
37 - Quid pro quo. This means not punishing mistakes, even if they lead to harm, unless they are the result of gross negligence, recklessness or malicious behaviour (all of which should - of course - be punished appropriately). Non-compliance with ‘learning’ or ‘safety’ investigations should also be deemed a breach of professional codes, and should itself result in investigation and, where appropriate, punishment. The ‘compulsion to assist safety investigations’ is counterbalanced by ensuring the ‘confidentiality of witness statements’. Confidentiality of statements given to safety investigations does not confer immunity or impunity from any other process, but is one part of a tried-and-tested method for gathering vital information through safety investigations in other industries.
38 - If there’s a will… I look forward with both optimism and expectation. I firmly believe that all of the problems that contributed to Sam’s avoidable death, and the NHS’s failure to understand or investigate it, can be fully understood and learnt from (faster than many believe possible) if there is a will to do so. First we must fully understand the nature of the problems from as many perspectives as possible. Second, we all need to commit ourselves to, and invest ourselves in, making it work. It will require time and collaboration across all disciplinary, hierarchical and organisational boundaries. Thereafter, like anything that matters, it will require focus, feedback, and an ongoing determination to fix problems - rather than trying to hide or deny them - wherever and whenever they arise.
November 2016