Department of Health
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An NHS that learns from mistakes

Health Secretary yesterday updated Parliament on the measures taken to improve safety and openness in the NHS.

With permission, Mr Speaker, I would like to update the House on the steps the government is taking to build a safer 7-day NHS. We are proud of the NHS and what it stands for and proud of the record numbers of doctors and nurses working for the NHS under this government. But with that pride in the NHS comes a simple ambition: that our NHS should offer the safest, highest quality care anywhere in the world. Today we are taking some important steps to make that possible.

In December, following problems at Southern Health, I updated the House about the improvements we need to make in reporting and learning from mistakes. NHS professionals deliver excellent care to around 650,000 patients every day, but we are determined to support them to improve still further the quality of the care we offer. So this government has introduced a tough and transparent new inspection regime for hospitals, a new legal duty of candour to patients and families who suffer harm and a major initiative to save lives lost from sepsis. As a result of these measures, according to the Health Foundation, the proportion of people suffering from the major causes of preventable harm has dropped by a third in the last 3 years.

But still we make too many mistakes. Twice a week in the NHS we operate on the wrong part of someone’s body and twice a week we wrongly leave a foreign object in someone’s body. The pioneering work of Helen Hogan, Nick Black and Ara Darzi has estimated that 3.6% of hospital deaths have a 50% or more chance of being avoidable, which equates to over 150 deaths every week.

We should remember that, despite this, our standards of safety still compare well to many other countries. But I want England to lead the world in offering the highest possible standards of safety in healthcare so today I am welcoming to London health ministers and healthcare safety experts from around the world for the first ever ministerial-level summit on patient safety.

I am co-hosting the summit with the German Health Minister, Hermann Grohe, who will host a follow-up summit in Berlin next year. Other guests will include Dr Margaret Chan, Director General of the World Health Organisation, Dr Gary Kaplan, Chief Executive of the renowned Virginia Mason Hospital in Seattle, Professor Don Berwick and Sir Robert Francis QC.

In the end, Mr Speaker, no change is permanent without real and lasting culture change. And that culture change needs to be about 2 things: openness and transparency about where problems exist, and a true learning culture to put them right.

With the new inspection regime for hospitals, GP surgeries and care homes, as well as a raft of new information now published on My NHS, we have made much progress on transparency. But as Sir Robert Francis’s Freedom to Speak Up report told us, it is still too hard for doctors, nurses and other frontline staff to raise concerns in a supportive environment.

Other industries – in particular the airline and nuclear industries – have learned the importance of developing a learning culture and not a blame culture if safety is to be improved. But too often the fear of litigation or professional consequences inhibits the openness and transparency we need if we are to learn from mistakes.

So following the commitment I made to Parliament at the time of the Morecambe Bay investigation, we will from 1 April 2016 set up our first ever independent Healthcare Safety Investigation Branch. Modelled on the Air Accident Investigation Branch that has been so successful in reducing fatalities in the airline industry, it will undertake timely, no-blame investigations.

As with the Air Accident Investigation Branch, I can today announce that we will bring forward measures to give legal protection to those who speak honestly to Healthcare Safety Investigation Branch investigators.

The results of such investigations will be shared with patients and families, who will therefore get to the truth of what happened much more quickly. However, unlike at present they will not normally be able to be used in litigation or disciplinary proceedings, for which the normal processes and rules will apply. The ‘safe space’ they create will therefore reduce the defensive culture patients and families too often find meaning mean the NHS can learn and disseminate any lessons much more quickly so that we avoid repeating any mistakes.

My intention is to use this reform to encourage much more openness in the way the NHS responds to tragic mistakes: families will get the full truth faster; doctors will get support and protection to speak out; and the NHS as a whole will become much better at learning when things go wrong. What patients and families who suffer want more than anything is a guarantee that no-one else will have to re-live their agony. This new legal protection will help us promise them ‘never again’.

Fundamental to this is getting a strong reporting culture in hospitals where mistakes are acknowledged and not swept under the carpet. So today NHS Improvement has also published a Learning from Mistakes ranking of NHS Trusts. This draws on data from the staff survey and safety incident reporting data to show which trusts have the best reporting culture and which ones need to be better at supporting staff who wish to raise concerns. This will be updated every year in a new Care Quality Commission (CQC) State of Hospital Quality report that will also contain trusts’ own annual estimates of their avoidable mortality rates and have a strong focus on learning and improvement.

Furthermore, the General Medical Council and the Nursing and Midwifery Council guidance is now clear - that where doctors, nurses or midwives admit what has gone wrong and apologise, the professional tribunal should give them credit for that, just as failing to do so is likely to incur a serious sanction. The government remains committed to further reform that would allow professional regulators more flexibility to resolve cases without stressful tribunals.

This change in culture must also extend to trust disciplinary procedures. So NHS Improvement will ask for a commitment to openness and learning to be reflected in all trust disciplinary procedures and ask all trusts to publish a Charter for Openness and Transparency so staff can have clear expectations of how they will be treated if they report clinical errors.

Finally, from April 2018, the government will introduce the system of medical examiners recommended in the Francis Report. This will bring a profound change in our ability to learn from unexpected or avoidable deaths, with every death either investigated by a coroner or scrutinised by a second independent doctor. Grieving relatives will be at the heart of the process and will have the chance to flag any concerns about the quality of care and cause of death with an independent clinician, meaning we get to the bottom of any systemic failures in care much more quickly.

Taken together, I want these measures to help the NHS to become the world’s largest learning organisation as part of our determination to offer the safest, highest quality standards of care.

An NHS that learns from mistakes. One of the largest organisations in the world becoming the world’s largest learning organisation - that is how we will offer the safest, highest quality standards of care in the NHS and I commend this statement to the House.


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