Copy of the speech from Helen Hughes, Chief Executive of Patient Safety Learning, given at the Professional Standards Authority for Health and Social Care (PSA) Parliamentary launch of the publication 'Safer care for all - Solutions from professional regulation and beyond'.
"Thank you for the opportunity to speak today and support the system leadership being shown by the PSA.
My name is Helen Hughes, and I am the Chief Executive of Patient Safety Learning, a charity and an independent voice for system wide change. We seek to improve patient safety through our policy, influencing and campaigning, as well as developing and promoting ‘how to’ resources such as the hub, our free learning platform for patient safety, and our recently launched organisational standards for patient safety.
At the heart of our approach is a commitment to listen to, learn from and promote the voice of the ‘patient safety front line' – patients and families, and the staff who dedicate their professional lives to providing safe and effective care.
That is why today I want to share with you Martha’s story. I wept, as I know many did, reading the article in this Saturday’s Guardian written by Martha’s mother, Merope Mills. Merope describes her article as 'an account of how Martha was allowed to die but also what happens when you have blind faith in doctors and learn too late what you should have known to save your child’s life.' It is a painful read; the horrendous inevitability of the narrative, knowing how it was going to end whilst seeing all the missed opportunities to intervene and act.
It’s a heart-breaking account of a mother being told not to be anxious as her daughter’s sepsis wasn’t recognised or treated until it was too late. King's [College London] has subsequently admitted a breach of duty of care and a catastrophic error.
We now understand in healthcare, that serious harm and preventable deaths are often not one single failure but a series of multiple failures and missed opportunities; there are many large holes in the Swiss cheese – those analogous cheese slice barriers to prevent error and harm in complex and complicated systems.
We know that it is essential for patient safety for organisations to have an open and fair culture, that all staff, patients and families can raise concerns, that staff can be critical friends to each other and to learn and apply that learning from investigations and reviews into unsafe care. We shouldn’t automatically blame the care giver but should seek to understand the causal factors so we can act swiftly and with resolve to prevent future harm.
Martha’s mother knew that Martha was deteriorating. What she didn’t know at that time was that the devastating signs of sepsis were not being recognised and, when action was taken, it was too little too late. When they did realise, the medical staff didn’t share with Martha’s parents that Martha was much worse than they expected, that she should have been urgently referred to Paediatric Intensive Care (PICU), and that part of the reason for that was a doctor’s dismissive attitude to less senior colleagues in PICU and misplaced confidence that junior medical staff had the necessary experience and expertise to escalate matters if Martha’s condition deteriorated. Merope describes that 'Martha died in part because of inflated egos'.
The hospital's policy is that parents being worried is a reason of itself to escalate. Merope was told not to look issues up on the internet but to 'trust the doctors, they know what they’re doing' and that there was no need for PICU doctors to pay Martha a bedside visit or do a review as it would increase the mother’s anxiety. Merope was told that her daughter was not going to die and that 'she should pull herself together.'
The hospital’s last-ditch effort to save Martha included an emergency referral to GOSH [Great Ormond Street Hospital]. Martha had fallen off a bike, sustained an injury to her pancreas that was diagnosed early and was treatable, but she was failed and died avoidably, aged 13.
So why is one tragic case relevant to today’s launch of PSA’s excellent report? I’ve eight reasons:
- It’s because all lives matter – Martha’s and the 11,000 other avoidable deaths each year in the UK. WHO state that unsafe care is one of the top ten killers globally, more so than deaths from road traffic accidents.
- We need to learn from error, harm and every preventable death and act on that learning, ensuring organisations have the systems and culture in place to deliver safe care.
- We need to listen and respond to the concerns of patients and families. There is strong evidence from research and personal testimony that listening to and learning from patients and families is not only courteous but absolutely essential in delivering safe care. Insights from patients and families are often different from those of staff and are invaluable in seeing ‘the bigger picture.’
- Organisations need to recognise that they need to transform themselves to deliver safe care. The avoidable deaths of Betsy Lehman and Josie King were catalysts for change by the leaders of Massachusetts General in Boston and John’s Hopkins in Baltimore. Will King's take this opportunity?
- That we learn from other safety critical industries and design and deliver systems-wide approaches to safety, as highlighted by the PSA and other experts such as Keith Conradi, the recent Chief Inspector of Investigations at HSIB.
- That we professionalise patient safety, so we have culture change, training for all staff that is informed by human factors and ergonomics, have standards for patient safety, such as those being called for by the PSA and those developed by Patient Safety Learning.
- And as PSA have called for, we don’t shy away from asking and answering the hard questions.
Our calls for action are:
- We do much more to address the scale of unsafe care that has not substantially changed in the UK in the last 20 years, despite the endeavours of many.
- We embed a just and fair culture that doesn’t seek to unfairly blame staff, acknowledging that the causal reasons for error and harm are mainly systemic and, to address that, we need system-wide and organisational commitment to change.
- We address the corrosive power hierarchies and egos of some senior clinicians and leaders who fail to acknowledge their role in setting the right culture and standards for performance and behaviour.
- We provide staff with the right resources to deliver safe care and to support and empower staff to speak up for patient safety.
- We recognise that staff safety and patient safety are two sides of the same coin, and we ensure that safety is a core purpose.
- We listen to and engage with patients in real time, as part of the team, not just when we learn retrospectively from the harrowing insight into avoidable deaths like Martha’s."