NHS: Learning from Mistakes

Philippa Whitford Excerpts

Wednesday 9th March 2016 Commons Chamber

[Mr Hunt]

I thank my right hon. Friend for her campaigning work on sepsis. Indeed, I have met the Mead family with her. She does a fantastic job with the all-party parliamentary group on sepsis. We announced a plan in January last year as this is a major area where we need to increase knowledge both inside the NHS and among the general public. As I mentioned a couple of weeks ago at a meeting organised by the all-party group, we are now looking at putting in place a public information campaign. We need to establish whether that should be about just sepsis, or whether it should be a more general public information campaign to help parents to understand when they need to worry about a fever, which is very common among small children and might be due to reasons other than sepsis, with meningitis being an obvious one. We are doing that detailed work now and we want to get this absolutely right, but I commend her persistence in ensuring that we deliver our commitments in this area.

[Dr Philippa Whitford (Central Ayrshire) (SNP)]

I welcome the statement from the Secretary of State, particularly with regard to the establishment of medical examiners, which we have had in Scotland since last year. I, too, ask why there is a delay of another two years before that comes on stream. As a doctor, the thing that always seemed obvious to me was what might have made a difference with Shipman. Of all the things that have been enacted, someone reviewing deaths might have made that difference. I do not underestimate the importance of audit, and learning from routine audit, rather than depending on just whistleblowing.

In Scotland, we had an audit of surgical mortality in the 1990s. The first thing that that showed was the people dying who had not had a sufficiently senior surgeon involved in their case. That was discussed with the profession, and practice changed. Future years identified a situation with a consultant surgeon at the front line and a junior anaesthetist, but that, too, changed. The audit identified the lack of high-dependency nursing units for the sickest patients. I suggest that working with such an audit and the profession, as we have done for coming up to 20 years, would have allowed the evolution of a stronger, safer seven-day emergency service. I again call on the Secretary of State to commit to looking at a surgical approach, the things that are missing—access to scans and radiology—and perhaps more senior review and senior involvement. This is not about junior doctors and it is not blanket.

We also need to look at the ratio of staff. Francis and other research have shown the importance of nursing staff. Staff who do not have a minute to stop and think will make mistakes, and will not have time to report them. We need to make this easy. There must be a culture in which people have the time to minimise mistakes.

I have a final plea. The Secretary of State is offering more support to whistleblowers, but a review and reconciliation for those who have been badly treated in the past might give people more confidence that, if they step up and report something significant, they will not be hung out to dry, as has been the case previously.

[Mr Hunt]

I contrast the tone of the hon. Lady’s response with that of the shadow Health Secretary. Although I by no means agree with everything she said, she does make some important points.

It is not the case that we have delayed the medical examiners scheme. In the previous Parliament, we had pilots so that we could understand exactly how the examiners would work. That is relevant to the hon. Lady’s other point about audit, with which I completely agree. One thing that medical examiners will be able to do is to look for unexpected or unexplained patterns in deaths. Obviously, the vast majority of deaths are routine, predictable and expected, but those examiners will be able, looking at audit tools, to identify where there are things to worry about, which is why this is an important next step.

With respect to whistleblowers, I will reflect on what the hon. Lady says. We are trying to eliminate the need for things ever to get to the point where someone has to become a whistleblower. We want to ensure that people are supported to speak out about mistakes they have seen or made and concerns that they have, and that they are confident that they will be listened to. We are publishing a table today about the quality of the reporting culture. Much of the raw data that allow us to rank trusts on the quality of reporting data come from the NHS staff survey, which asks staff how valued they think they are, and how safe and easy it is to raise concerns. That is why this is a big step forward.