Failures in NHS lesson learning
John Tingle, Lecturer in Law, Birmingham Law School, University of Birmingham, discusses patient safety in the light of the recently published Ockenden report
There are several apparently intractable patient safety issues that currently plague the NHS and have done so for decades. These issues strike at the core of NHS care delivery. There is a patent failure of some nurses, doctors and other health carers to properly learn from past adverse healthcare events and to change practices. The NHS has a defensive nature when it comes to responding to complaints, claims of harm and patient safety error reporting. There is a lack of a comprehensive NHS patient safety culture and nurses and doctors fail to put the patient first.
Ensuring that the patient's interests and wellbeing are protected should be the guiding beacon for everything that is done in health care.
Current and past patient safety crises show that these issues have not been sufficiently addressed in the past and are constant themes that require urgent attention in the NHS today.
An almost stoic refusal by sections of the NHS to engage with these issues can be seen in many reports. Care Quality Commission (CQC) inspection reports often lament the lesson learning failures in trusts, with trusts failing to advance patients' rights and interests, along with predominantly defensive cultures. Major reports into NHS patient safety crises such as at Mid Staffordshire (Francis, 2013), Morecambe Bay (Kirkup, 2015), and now Shrewsbury and Telford (Ockenden, 2022) all tell largely the same story.
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