- NHS Resolution creates advice for trusts over responding to patient safety incidents
- Charter encourages trusts to make commitments towards a just and learning culture
- Director warns against knee-jerk reactions such as disciplinary processes
NHS staff are requiring “significant” amounts of support after being involved in patient safety incidents, prompting a national body to draw up a new charter for how trusts should respond.
The “Being Fair” charter has been created by NHS Resolution (formerly the NHS Litigation Authority) in a bid to ensure trusts respond to incidents in a way that is fair to both the patient and staff involved, and that errors are not repeated.
Each year the NHS pays out an average of £2.2bn as a result of clinical negligence claims.
Denise Chaffer, director of safety and learning at NHS Resolution, said: “Staff also are requiring significant amount of support if they’re involved in incidents and we’re seeing quite a difference in the approach taken across the country.
“There are a lot of conversations about the importance of having a just and learning culture, but what we wanted to do is provide materials about how we can make that happen.”
The charter, which will be issued to trust boards and regulators, recommends that trusts make 20 commitments, including:
- Taking the blame out of failure and changing the mindset from blame to learning, while retaining accountability;
- Notifying people who report concerns in a “timely way” of steps taken in response;
- Ensure suspension is rare and never a kneejerk response to an incident; and
- Ensure that advice given by occupational health workers is followed to help with staff wellbeing.
Additional guidance will be published alongside the charter, according to Ms Chaffer.
Speaking at the Patient Safety Congress about how the NHS should respond to errors and mistakes, she said: “The most important thing to say is this isn’t something that’s different for staff and patients – it’s seeing staff and patients as equals in the same process and that we look to do whatever we can to support both to get some kind of resolution.
“This is about point of resolution for staff and patients. This is not about intent, recklessness, dishonesty or cover-ups. This is about understanding what’s happened rather than who’s responsible.
She said individual trusts deal with incidents very differently, and she cautioned against launching disciplinary processes straight away.
“What we are saying here is at the very least have a conversation and talk these things through before people move into disciplinary processes or investigation process,” she said.
That advice was supported by Roger Kline – a research fellow at Middlesex University Business School – who told the congress there is no evaluation of whether disciplinary procedures in the NHS achieve what they are supposed to do.
“In 2017 in England there were 16,000 disciplinary investigations in NHS trust at a very considerable cost of management time, staff health and so on,” he said.
“There were no obvious correlations between the levels of disciplinary action and quality and safety of care provided in organisations.”
The charter and guidance will be available to read on NHS Resolution’s website.
HSJ Patient Safety Congress