PATIENT SAFETY NOW

Often after serious incidents there is a call for an independent inquiry. A chair is appointed. Years pass. Millions of pounds are spent. Thousands of pages are written. Recommendations are made. Everyone promises that lessons will be learned.

Then, a few years later, there is another and another. I have been working in the NHS for over 40 years and I have witnessed this time and time again.

This isn’t a criticism of the people who run inquiries. Nor is it a criticism of the families whose persistence often makes an inquiry needed. Many inquiries have given voice to people who had been ignored for far too long.

The question is whether inquiries, as we currently design them, are still the right tool for improving patient safety.

Increasingly, I think the answer is no.

Health service inquiries have become slow, very expensive and by their very nature always retrospective. They can take years to report, by which time organisations have changed, leaders have moved on, staff have left and services have been redesigned. The context has shifted before the findings have even been published.

They also create expectations that are almost impossible to meet.

Families understandably hope that an inquiry will provide answers, accountability and crucially, reassurance that others will not experience the same harm. Staff hope that the complexity of healthcare will be recognised.

Everyone expects change. Yet too often the majority of people involved leave disappointed.

The recommendations frequently feel familiar because we have seen them before: improve leadership, strengthen governance, listen to patients, improve communication, enhance training, embed a culture of openness and so on.

All are worthwhile, but none are new. Repeating recommendations is not enough. We need to spend time, effort and resources on addressing the past recommendations before we keep adding a load of new ones.

Inquiries have become very good at describing what went wrong but much less effective at understanding the conditions that allowed the same patterns to emerge.

Rather than being retrospective we would better off if they were used to understanding how work is actually done, how we can help organisations detect weak signals before people are harmed, how we can help staff raise concerns without fear, how we can improve the way leaders respond to bad news, and how we can understand how systems adapt when pressures increase.

These are everyday activities. Everyday safety intelligence. What if we redirected even a fraction of the resources devoted to inquiries into learning all of that and creating a safety intelligence system?

We should be as interested in the small warning signs as we are in the major failures.

Inquiries (and our current approach to safety) is helps us look backwards when what patient safety really needs is a much better way of looking forwards?