'We need to change the culture in the NHS': Ahead of next week's Mid Staffs report, three people explain how patient safety and care could be improved.
When Dr Barry Sullman was working as a junior doctor in the early 1990s, he had the worst experience that any young, trainee doctor could have. As part of the treatment of a 16-year-old boy with leukaemia, he was asked to administer an injection of a cancer drug called vincristine. On the day, due to an organisational error, vital information on administering the drug went missing and a consultant was not available to supervise the procedure. Sullman and his colleague mistakenly injected the drug into the boy's spine in error, rather than intravenously and, as a result, the boy later died in hospital. After a trial, the two junior doctors were convicted of manslaughter, and given a suspended sentence. The verdict was later overturned on appeal.
Sullman had never spoken about his experience publicly until a recent healthcare conference, but he believes that traditional medical training was partly to blame for the tragic error. More than 20 years later, he thinks things still haven't changed in the NHS.
"When you're in medical school, you're taught all about the theory, all the complex stuff about physiology and so on, but you're not given any practical guidance or instruction, for example, on how to give an injection, and all that is left until you do your in-house training in a hospital," says Sullman, who now works as a GP.
"But in the modern NHS, and especially in a busy trust hospital," he says, "your colleagues can often be either too busy, or needed elsewhere, to take time to explain things properly – it's not that they don't want to support you, it's just that they have competing priorities all the time.
"Under the current adversarial system, if something goes wrong the reaction is to find someone to blame, and this is not geared towards improving patient care. Instead of spending vast amounts of money on new medical technology and advanced IT, the NHS should be spending more on medical training and 'hands-on' experience for doctors, nurses and other health professionals."
He is not alone in believing the NHS needs to change its culture fundamentally to improve standards of patient safety and to enable patients and their families to understand what has happened when things go wrong. Next week, the report will be published of a public inquiry into the scandal of care in hospitals run by the Mid Staffordshire NHS foundation trust, where between 400 and 1,200 patients may have died needlessly between 2005 and 2009. The inquiry chairman, Robert Francis QC, is expected to be highly critical of the culture of the health service and to suggest that hospitals that cover up doctors' mistakes should face fines and possible closure.
Martin Bromiley, an airline pilot, whose wife Elaine died in 2005 at the age of 37 after a routine operation went badly wrong at a hospital in the home counties, had told the Mid Staffs inquiry that he wants nothing less than a body similar to the Air Accidents Investigation Branch to be set up to look into major failings in the health service.
"Elaine had gone into hospital to have an operation to correct a problem with her sinuses, and I took her into the hospital for the operation that day. Later that morning I got a phone call to say her airway had collapsed, her oxygen levels had fallen to a very low point and they had decided the safer option was to let her wake up naturally, but unfortunately she hadn't done so," says Bromiley.
"In consultation with the consultants, I decided to switch off her life support system, and Elaine died 13 days after the original operation."
Bromiley says it took a great deal of effort on his part to find out what had happened, and even today he believes that he knows "about 80%" of the story.
The hospital's own inquiry found that the lead consultant had, in his own words, "lost control" of the situation. "There was certainly a breakdown in the decision-making processes and it appears that communication dried up among the consultants," says Bromiley.
He has never named the hospital because he stresses that the problems that led to Elaine's death are systemic across the whole of the health service.
Training in human factors that can influence behaviour at work in a way that may affect health and safety has been mandatory for pilots and crew in the aviation industry since the mid-1990s. Bromiley has years of experience of performing checks, assessing safety risks and discussing potential problems with colleagues. It extends to good team communication, where potential problems are openly discussed, not kept under wraps, and he was astonished at the lack of a similar system in healthcare.
"In my wife's case, we had a breakdown of leadership, of awareness, of prioritisation, of decision-making, of communication and of assertiveness. Since then, I've been trying to understand why training in awareness of these human factors isn't part of clinical practice."
Tony Giddings, a retired NHS general surgeon, has been one of a small minority of doctors who have been calling for a radical change in culture in healthcare for some years. He was a member of the initial Healthcare Commission investigation at Mid Staffs , which uncovered "appalling" failures in care and led to the lengthy public inquiry being set up.
"We need to change the whole culture in the NHS to one of more openness, where we accept that humans are fallible and that making errors is bound to happen, and we need to be able to share the learning from these errors to improve patient care," says Giddings. "At the moment what we have is a 'blame culture' where everybody is afraid to admit to an error, which we all make at some time, and potential whistleblowers are afraid to come forward because it may affect their career or they may be victimised. As clinicians we have a duty of care to patients, and organisations have to do more to show they have the same duty of care, by disclosing to patients what has happened when things go wrong."
He has set up a campaign group, called Risky Business to lobby for the introduction of human factors training in medical education and hospitals.
Since 2003, the National Patient Safety Agency has collated figures for England on incidents of patient harm and deaths caused by healthcare procedures in hospitals. Between October 2011 and March 2012 – the latest figures available – of the 612,414 total patient safety incidents reports, 5,235 patients died or were severely harmed. But, as Giddings points out, this is only recording the "symptoms" of what is going wrong in healthcare. "The very fact that data is anonymised means that it can't be acted upon and the figures are recording the outcomes of poor procedures in hospitals, but it's the root causes of the errors – poor safety procedures and lack of communication – that need to be tackled."
Bromiley hopes that the NHS will reflect on next week's Francis report and get properly to grips with human factors as the key to understanding why the system does not always deliver safety. "This is the approach that every other safety-critical industry has taken and the public should expect the NHS to be no different. Every person, whether wife, husband, child or parent, who dies from avoidable harm is an unnecessary waste of life," he says.
As for Sullman, who has thought about what happened that fateful day for nearly a quarter of a century, he says: "Probably all medical error has a multifactorial origin, yet the kneejerk reaction is to find someone and punish them. The system is never put right. Just some poor guy is hung up for all to see instead." The Guardian
When Dr Barry Sullman was working as a junior doctor in the early 1990s, he had the worst experience that any young, trainee doctor could have. As part of the treatment of a 16-year-old boy with leukaemia, he was asked to administer an injection of a cancer drug called vincristine. On the day, due to an organisational error, vital information on administering the drug went missing and a consultant was not available to supervise the procedure. Sullman and his colleague mistakenly injected the drug into the boy's spine in error, rather than intravenously and, as a result, the boy later died in hospital. After a trial, the two junior doctors were convicted of manslaughter, and given a suspended sentence. The verdict was later overturned on appeal.
Sullman had never spoken about his experience publicly until a recent healthcare conference, but he believes that traditional medical training was partly to blame for the tragic error. More than 20 years later, he thinks things still haven't changed in the NHS.
"When you're in medical school, you're taught all about the theory, all the complex stuff about physiology and so on, but you're not given any practical guidance or instruction, for example, on how to give an injection, and all that is left until you do your in-house training in a hospital," says Sullman, who now works as a GP.
"But in the modern NHS, and especially in a busy trust hospital," he says, "your colleagues can often be either too busy, or needed elsewhere, to take time to explain things properly – it's not that they don't want to support you, it's just that they have competing priorities all the time.
"Under the current adversarial system, if something goes wrong the reaction is to find someone to blame, and this is not geared towards improving patient care. Instead of spending vast amounts of money on new medical technology and advanced IT, the NHS should be spending more on medical training and 'hands-on' experience for doctors, nurses and other health professionals."
He is not alone in believing the NHS needs to change its culture fundamentally to improve standards of patient safety and to enable patients and their families to understand what has happened when things go wrong. Next week, the report will be published of a public inquiry into the scandal of care in hospitals run by the Mid Staffordshire NHS foundation trust, where between 400 and 1,200 patients may have died needlessly between 2005 and 2009. The inquiry chairman, Robert Francis QC, is expected to be highly critical of the culture of the health service and to suggest that hospitals that cover up doctors' mistakes should face fines and possible closure.
Martin Bromiley, an airline pilot, whose wife Elaine died in 2005 at the age of 37 after a routine operation went badly wrong at a hospital in the home counties, had told the Mid Staffs inquiry that he wants nothing less than a body similar to the Air Accidents Investigation Branch to be set up to look into major failings in the health service.
"Elaine had gone into hospital to have an operation to correct a problem with her sinuses, and I took her into the hospital for the operation that day. Later that morning I got a phone call to say her airway had collapsed, her oxygen levels had fallen to a very low point and they had decided the safer option was to let her wake up naturally, but unfortunately she hadn't done so," says Bromiley.
"In consultation with the consultants, I decided to switch off her life support system, and Elaine died 13 days after the original operation."
Bromiley says it took a great deal of effort on his part to find out what had happened, and even today he believes that he knows "about 80%" of the story.
The hospital's own inquiry found that the lead consultant had, in his own words, "lost control" of the situation. "There was certainly a breakdown in the decision-making processes and it appears that communication dried up among the consultants," says Bromiley.
He has never named the hospital because he stresses that the problems that led to Elaine's death are systemic across the whole of the health service.
Training in human factors that can influence behaviour at work in a way that may affect health and safety has been mandatory for pilots and crew in the aviation industry since the mid-1990s. Bromiley has years of experience of performing checks, assessing safety risks and discussing potential problems with colleagues. It extends to good team communication, where potential problems are openly discussed, not kept under wraps, and he was astonished at the lack of a similar system in healthcare.
"In my wife's case, we had a breakdown of leadership, of awareness, of prioritisation, of decision-making, of communication and of assertiveness. Since then, I've been trying to understand why training in awareness of these human factors isn't part of clinical practice."
Tony Giddings, a retired NHS general surgeon, has been one of a small minority of doctors who have been calling for a radical change in culture in healthcare for some years. He was a member of the initial Healthcare Commission investigation at Mid Staffs , which uncovered "appalling" failures in care and led to the lengthy public inquiry being set up.
"We need to change the whole culture in the NHS to one of more openness, where we accept that humans are fallible and that making errors is bound to happen, and we need to be able to share the learning from these errors to improve patient care," says Giddings. "At the moment what we have is a 'blame culture' where everybody is afraid to admit to an error, which we all make at some time, and potential whistleblowers are afraid to come forward because it may affect their career or they may be victimised. As clinicians we have a duty of care to patients, and organisations have to do more to show they have the same duty of care, by disclosing to patients what has happened when things go wrong."
He has set up a campaign group, called Risky Business to lobby for the introduction of human factors training in medical education and hospitals.
Since 2003, the National Patient Safety Agency has collated figures for England on incidents of patient harm and deaths caused by healthcare procedures in hospitals. Between October 2011 and March 2012 – the latest figures available – of the 612,414 total patient safety incidents reports, 5,235 patients died or were severely harmed. But, as Giddings points out, this is only recording the "symptoms" of what is going wrong in healthcare. "The very fact that data is anonymised means that it can't be acted upon and the figures are recording the outcomes of poor procedures in hospitals, but it's the root causes of the errors – poor safety procedures and lack of communication – that need to be tackled."
Bromiley hopes that the NHS will reflect on next week's Francis report and get properly to grips with human factors as the key to understanding why the system does not always deliver safety. "This is the approach that every other safety-critical industry has taken and the public should expect the NHS to be no different. Every person, whether wife, husband, child or parent, who dies from avoidable harm is an unnecessary waste of life," he says.
As for Sullman, who has thought about what happened that fateful day for nearly a quarter of a century, he says: "Probably all medical error has a multifactorial origin, yet the kneejerk reaction is to find someone and punish them. The system is never put right. Just some poor guy is hung up for all to see instead." The Guardian
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