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Independent medical examiners to review all deaths from April 2018

All deaths will be subject to independent medical review and a Healthcare Safety Investigation Branch will be established as part of a range of measures to improve safety and transparency in the NHS, the health secretary will announce today.

Speaking at the two-day Global Patient Safety Summit, Jeremy Hunt will promise that independent medical examiners will review and confirm the causes of all deaths from April 2018, following a recommendation originally made in the Shipman Inquiry and by Robert Francis following the inquiry into the Mid-Staffordshire Trust.

Other safety measures will include an independent Healthcare Safety Investigation Branch and legal safe spaces for those co-operating with investigations following hospital mistakes.

Hunt said: “A huge amount of progress has been made in improving our safety culture following the tragic events at Mid Staffs but to deliver a safer NHS for patients, seven days a week, we need to unshackle ourselves from a quick-fix blame culture and acknowledge that sometimes bad mistakes can be made by good people.

“It is a scandal that every week there are potentially 150 avoidable deaths in our hospitals and it is up to us all to make the need for whistleblowing and secrecy a thing of the past as we reform the NHS and its values and move from blaming to learning.”

The first annual ‘Learning from Mistakes’ league from NHS Improvement, published as part of the reforms, showed that 32 out of 230 organisations have a poor reporting culture and 78 raise significant concerns.

Hunt’s announcement comes as Dame Eileen Sills, the first UK national guardian for whistleblowers, announced that she was stepping down from her post after just two months.

Recent potential scandals in NHS trusts include allegations that South East Coast Ambulance Trust introduced a secret protocol to downgrade ambulance calls, and that Queen Elizabeth Hospital in Birmingham had a high cardiac surgery fatality rate because of problems caused by “fragmented and dysfunctional” leadership.

Under the new reforms, all NHS trusts will also be required to publish estimates of their own non-comparable mortality rates, making England the first country in the world to introduce this measure, and to publish a charter for openness and transparency so staff will have clear expectations about how they will be treated if they witness clinical errors.

NHS England will also work with the Royal College of Physicians to develop a standardised method for reviewing the records of patients who have died in hospital.

New General Medical Council and Nursing and Midwifery Council guidance will ensure that when NHS staff are honest about mistakes and apologise, a professional tribunal gives them credit for that and failing to do so could incur a serious sanction.

James Titcombe, Morecambe Bay parent and national adviser on patient safety, culture and quality, said: “Time and time again, we hear the promise that ‘lessons will be learned’ following reports about systemic failures and individual stories of avoidable harm and loss in the NHS. Yet, far too often, the same mistakes are repeated and meaningful learning and lasting change simply doesn’t happen.

“These announcements are about saying ‘never again’ - the measures announced are major steps that will help move the NHS towards the kind of true learning culture that other high risk industries take for granted.”

UPDATE 11.45am

Commenting on the new 'Learning from Mistakes' league Saffron Cordery, director of policy and strategy, said: 

“The information published today should be viewed alongside other measures including the CQC’s inspection judgement on safety, and consideration must be given to the different types of risk and case mix which different providers are managing every day. For this reason, while benchmarking information is always useful, we would question the added value of the league table format. Being top or bottom of such a league must always be seen in the broader context. Purposeful change comes from within and it is crucial that NHS providers are involved in shaping how today’s announcements are implemented at the frontline."

(Image c. Peter Byrne)


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