A ‘no blame’ culture in the NHS runs the risk of exonerating genuine wrong-doers - it’s time to move rapidly to a ‘just culture’, writes James Titcombe

Last month, the Parliamentary and Health Service Ombudsman (PHSO) published a report relating to the tragic death of three year old Sam Morrish, who died in 2010 from sepsis. In 2014, the PHSO published a report that found Sam would have survived had he received appropriate care and treatment.

However, whilst the 2014 report confirmed that Sam’s death was avoidable, it didn’t satisfactorily explain why the local NHS failed to uncover what happened and therefore couldn’t ensure that necessary learning took place. At the request of Sam’s parents, the PHSO undertook a new investigation to look at why.

The report found that the local investigation process was not fit for purpose, was not sufficiency independent, inquisitive, open or transparent and that the people carrying out the investigation were not sufficiently trained. It’s a hard hitting, compelling document that builds on the now strong evidence base that tells us there is an urgent need for change in the way the NHS responds and learns from mistakes.

This report and its recommendations will help ensure that others don’t have to go through what Sam’s family have. Please read it.

“No blame” is no use

When the report was published, ombudsman Dame Julie Mellor commented: ”We hope that this case acts as a wake-call up for NHS leaders to support a no-blame culture in which leaders and staff in every NHS organisation feel confident to find out if and why something went wrong and to learn from it.’

The sentiment of the message is absolutely right, but as with so many areas of healthcare, language can be very important and the phrase ‘no-blame’ is one which I know can lead to misunderstandings. Although ‘no blame’ is still frequently mentioned in healthcare as being desirable, it is outdated and has largely been superseded in other industries by the concept of ‘just culture’.

Just culture

In May this year the Expert Advisory Group, established to provide advice of how the new Healthcare Safety Investigations Branch (HSIB) should operate, recommended that the promotion of a ‘just culture’ should be a central principle in the operation of the new organisation.

“The branch must promote the creation of a just safety culture, a shared set of values in which healthcare professionals trust the process of safety investigation; and are assured that any actions, omissions or decisions that reflect the conduct of a reasonable person under the same circumstances will not be subject to inappropriate or punitive sanctions.”

This describes the culture that most people would agree we need to promote, foster and support in healthcare.

Promoting a ‘just culture’ and the role of HSIB

So how do the principles of a ‘just’ culture align with the new Healthcare Safety Investigation Branch? HSIB has introduced the concept of a ‘safe space’, with investigations that focus on learning, not blame.

As Sam’s story so powerfully highlights, following any incident of avoidable harm or loss in healthcare, the system as a whole has an absolute duty to respond in a way that achieves a number of different things.

The patient, family and staff involved need to be supported with compassion and care.

The facts of what happened need to be established thoroughly and accurately to allow an analysis of the sequence of events, identification of the contributory factors and a deep understanding of what happened and why.

We know from the experience of other safety critical industries and healthcare organisations across the globe that the fastest and most effective way of establishing the facts, identifying the contributory factors and making the changes needed to reduce the risk of harm to patients, is when the process of safety investigation is clearly separated from processes that look at individual performance.

But what does a ‘safe space’ actually mean? This is an area that I know has caused a lot of concern among patients and patient groups. Does this mean information about an incident or healthcare failure could effectively be hidden from patients and the families of those harmed?

The Expert Advisory Group was clear on this: “The branch must provide families and patients with all relevant information relating to their care, reflecting the responsibilities of healthcare providers to uphold the duty of candour”.

The concept of a ‘safe space’ must never be allowed to negate the duty of candour. Rather the ‘safe space’ concept will allow healthcare staff and families involved in safety investigations to disclose information knowing that it will only be used for learning. If this leads to quicker identification of the issues and changes needed to protect future patients from harm, it has to be the right way forward.

Restoring pride in patient safety professionals

These are not easy issues to get right. The need to improve the quality of incident investigation and learning from patient safety failures in the NHS has been highlighted consistently since at least 2001, when Sir Ian Kennedy published his report into serious failures at Bristol.

The tragic loss of Sam Morrish and the failure of the system to properly respond and learn from his death highlights so powerfully why rapid change is now needed. The PHSO report welcomes the establishment of HSIB but acknowledges that the vast majority of healthcare investigations will continue to happen locally. It recommends that a national system of accredited training for those who carry out NHS investigations is implemented.

These important recommendations will take time to put in place, but all NHS organisations should review and act now to ensure their patient safety and investigation teams are fully resourced, well trained and that their organisations support and promote a just culture. This means always ensuring families and patients are provided with truthful and accurate facts about what happened, robust investigations for learning that identify any risks and necessary changes to protect patients and effective, separate processes for ensuring that individuals are properly held to account for actions that fall outside acceptable boundaries.

Sam’s case highlights yet again why the NHS simply must do things differently. But the truth is that getting these issues right isn’t easy. It takes good leadership as well as a high degree of expertise and skill. The challenge now for both HSIB and individual organisations is to get these principles right in practice and demonstrate a truly just safety culture.

If this happens, trust among staff and patients will grow, the sense of fear that so often inhibits open reporting and learning in the NHS will be greatly diminished and we will have succeeded in taking a huge step forward towards making the NHS safer and fairer for everyone.

James Titcombe OBE became involved in patient safety following the loss of his baby son due to failures in his care at Morecambe Bay Trust in 2008. Formerly the national adviser for safety for the Care Quality Commission, he is now a patient safety specialist working for Datix.