Learning from the past: inquiries into major failuresinquiries into major failures in the NHS since 1968

Kieran WalsheProfessor of Health Policy and ManagementManchester Business Schoolkieran walshe@mbs ac ukkieran.walshe@mbs.ac.uk

Overview

• Inquiries into major failures in care in the NHS – some history and developmenthistory and development

• Inquiries and investigations: purpose and process

• What we learn about healthcare organisations from• What we learn about healthcare organisations from inquiries into major failures in care

• Conclusions/issues for discussionCo c us o s/ ssues o d scuss o

History and development

• “Sans everything: a case to answer” and the whitewash

• Ely Hospital – the first modern inquiry in 1969• Ely Hospital – the first modern inquiry in 1969

• The long-term care inquiries of the 1970s and 1980s – South Ockenden, Farleigh, Napsbury, Normansfield…

• The big inquiries of the 1990s – Alder Hey, Ashworth, Ledward, Bristol, Shipman

• The arrival of CHI/HC/CQC with statutory powers of investigation: e a a o C / C/CQC t statuto y po e s o est gat oHealthcare Commission did 14 investigations 2004-2007 incl Northwick Park, Stoke Mandeville, Cornwall Partnership, etc

• More recent inquiries: Neale Ayling Kerr/HaslamMore recent inquiries: Neale, Ayling, Kerr/Haslam

• Most recently: Mid-Staffordshire Hospital

Sans Everything: the inquiry

• “None of the allegations of cruelty or ill-treatment is justified.. The charges of laziness and dishonesty are j g yfalse and scandalous…”

• “The Matron took no action upon the complaints because being a kind and gentle person she did notbecause.. being a kind and gentle person she did not wish to needlessly upset her staff by seeming to entertain unjust reflections upon their professional competence”competence

• “[The complainant] proved a most unreliable witness whose judgement was manifestly unsound… she is a j g yrather solitary person with a somewhat simple mind..”

Ely Hospital: the inquiry

• Most allegations of mistreatment or cruelty found proven – “Generally the situation at Ely has proved to p y y pbe sufficiently disturbing to make XY’s concern well justified”

• “Lax and old fashioned standards of nursing• Lax and old-fashioned standards of nursing, reminiscent in too many ways of the old era of custodial care, have been accepted”

• “Virtual isolation… an inward looking community”; “Serious overcrowding”; “Low standards of medical care”; “The HMC and its officers must accept the ; pprincipal responsibility for the shortcomings identified”

Ely Hospital 1969 Mid-Staffordshire Hospital 2009• “Lax and old fashioned standards of

nursing, reminiscent of the old era of custodial care have been accepted.”

• “Taken individually, many of the accounts I received indicated a standard of care which was totally unacceptable Together they

Ely Hospital, 1969 Mid-Staffordshire Hospital, 2009

“A d l l ttit d t d

unacceptable. Together, they demonstrate a systematic failure of the provision of good care.”

“I id t ti t• “An unduly casual attitude towards sudden death [and] inadequate systems for reporting incidents”

• “Incident reporting systems were criticised by many staff... The Inquiry found evidence that a number of deaths had not been reported in this system when they should have

• “All the male wards are seriously overcrowded. The buildings are old and ill-designed. The standards of

system when they should have been.”

• “More often there were inadequate b f t ff d t t d l ith

gamenity fall far short of what would nowadays be expected.... The staff establishment [of one ward] is half the minimum desirable...”

numbers of staff on duty to deal with the challenge of a population of elderly and confused patients.”

Ely Hospital 1969 Mid-Staffordshire Hospital 2009• “Members of the nursing staff who

were concerned about conditions must have come to feel that it was almost more than their professional

• “The few instances of reports by whistleblowers of which the Inquiry was made aware suggest that the Trust has not offered the support and

Ely Hospital, 1969 Mid-Staffordshire Hospital, 2009

almost more than their professional life was worth for them to voice any feelings of concern.”

pprespect due to those brave enough to take this step. The handling of these cases is unlikely to encourage others to come forward, and the responses to the investigation of the concerns

• “A structure of nursing administration which has resulted in virtual

to the investigation of the concerns raised have been ineffective.”

• “The Trust and its staff carried on much of its work in isolation from the wider NHS community It was not aswhich has resulted in virtual

isolation... in a close knit and inward looking community.”

“A lack of energ and sophistication

wider NHS community. It was not as open to outside influences and changes in practice as would have been the case in other places.”

• “The consultant body largely• “A lack of energy and sophistication in medical care and record keeping... The Physician Superintendent did too little to improve low standards of medical care.”

• The consultant body largely dissociated itself from management and often adopted a fatalistic approach to management issues and plans.” medical care. p

Ely Hospital 1969 Mid-Staffordshire Hospital 2009• “The HMC and its officers must

accept the principal responsibility for the shortcomings identified: an ineffective system of

• “The Board’s collective failure was perhaps that of never fully appreciating the risks to patients that were being taken on a day-

Ely Hospital, 1969 Mid-Staffordshire Hospital, 2009

an ineffective system of administration...”

g yto-day basis as a result of the deficiencies that they were seeking to tackle but had not yet dealt with. There was a degree of self satisfaction amplified by theself satisfaction, amplified by the achievement of FT status, and a failure to detect or react to the ever-strengthening wind of concern that blew round the

• “The RHB and its officers have

Trust.”

• “Concern is expressed that none of them from the PCT to thenot accepted any responsibility

for the inspection or supervision of standards at Ely and have done little.. Nor has the hospital been subject to any other system

of them from the PCT to the Healthcare Commission, or the local oversight and scrutiny committees, detected anything wrong with the Trust’s been subject to any other system

of inspection...”o g t t e ust s

performance until the HCC investigation.”

More inquiries• Allitt (Clothier inquiry)

• Ashworth (Blum Cooper inquiry)

Bristol (Kennedy inquiry)• Bristol (Kennedy inquiry)

• Alder Hey (Redfern inquiry)

• Ledward (Ritchie inquiry)ed a d ( tc e qu y)

• Shipman (Smith inquiry)

• Kerr/Haslam (Pleming inquiry)

• Neale (Matthews inquiry)

• Ayling (Pauffley inquiry)

Mid St ff d hi (F i i i )• Mid-Staffordshire (Francis inquiry)

International examples

• Untreated cervical cancer – Auckland, NZ

Contaminated blood products Canada• Contaminated blood products – Canada

• Poor paediatric cardiac surgery – Winnipeg, Canada

• Deliberate harming of patients Indiana USA• Deliberate harming of patients – Indiana, USA

• Cytology screening errors – Gisbourne, NZ

• Poor obstetric and gynaecology service – Perth AustraliaPoor obstetric and gynaecology service Perth, Australia

• Poor general surgery – Virginia, USA

• Unnecessary cardiac surgery – California, USAUnnecessary cardiac surgery California, USA

Trends and developments

• Increasing number, scale, scope and cost of inquiries• Greater rigour transparency and formality of process• Greater rigour, transparency and formality of process• Growing overlaps between different inquiries by

different bodies – often successive inquiries with qdifferent mandates and purposes

• New statutory role for Commission for Health Improvement/Healthcare Commission/Care QualityImprovement/Healthcare Commission/Care Quality Commission in investigations

The purpose of inquiries

• Establishing the facts

L i f t• Learning from events

• Catharsis or therapeutic exposure

• Public reassurance

• Accountability, blame and retribution

• Political considerations

Setting up inquiries

• Criteria for an inquirySerious harm or loss to patients– Serious harm or loss to patients

– New or poorly understood issues of concern– Widespread public concern and loss of confidencep p

• Role of the “egregious event”• Pressure from patients, the public and the mediap p

What kind of inquiry

• Internal NHS management inquiry

H lth C i i /C Q lit C i i• Healthcare Commission/Care Quality Commission investigation under s48 of Health and Social Care Act 2008

• External NHS private inquiry under s2 NHS Act 1977

• Statutory inquiry under NHS Act 1977 or Tribunals of Statuto y qu y u de S ct 9 o bu a s oInquiry (Evidence) Act 1921 (now replaced by Inquiries Act 2005)

Inquiry methods and issues

• Openness – meeting expectations and being effective and efficient

• Fairness – to all stakeholders• Rigour – validity and generalisability of findings, the g y g y g

inquiry as a case study• Cost – from £20k for an internal inquiry to £15+ million

for a public inquiryfor a public inquiry• Time – from weeks to 3+ years

Inquiry effects and impacts

• Effects through process and report publication• The impact of the inquiry process itself and its use by• The impact of the inquiry process itself and its use by

stakeholders/interest groups • Content of the inquiry report and recommendations q y p

and DH response• Common findings and lessons• Mechanisms for follow-up on wider implementation

Common findings

• Longstanding problems – exist for years or even decades before being surfaceddecades before being surfaced

• Well known but not tackled – high levels of tacit knowledge did not lead to actiong

• Causes of immense harm to patients, healthcare organisations, professionals

• Failures happen in dysfunctional organisations

• Similar major failures happen again and again and again…

Common findings

• Failures centre on an individual – but organisational pathology crucialpathology crucial

• Lack fundamental management systems, or they don’t work

• Poor clinical and managerial leadership

• Inward looking, introverted and closeda d oo g, t o e ted a d c osed

• Disempowered staff and patients

Common findingsE d i d i i h “ l b l ”• Endemic secrecy and protectionism – the “club culture” in healthcare

• Knowledge and responsibility fragmented – no one g p y gperson or organisation has authority and incentive to act

• Huge capacity for self-deception and post-hocHuge capacity for self deception and post hoc rationalisation – disbelieve the data

• Informal mechanisms for dealing with failures – exit without a fuss – move problems aroundwithout a fuss move problems around

• Many major failures probably remain undisclosed –we see the tip of the iceberg?

Conclusions and issues for discussion

• Inquiry costs and benefits – financial and other costs, impact on those involved new knowledge generatedimpact on those involved, new knowledge generated, other outputs/values

• Inquiry methodology – who chairs/leads, who q y gyinvestigates, risk of hindsight and other biases, how generalisable are findings,

f f• Learning from inquiries – methods and mechanisms for wider implementation, monitoring, follow-up