Article Text
Statistics from Altmetric.com
‘Organisational failure’ is central to medical ethics. In the National Health Service (NHS), we usually examine failures at hospital level. We have had around 100 hospital inquiries since the first in 1969, into Ely Hospital, Cardiff. This year, we had the Ockenden Report into Shrewsbury and Telford Hospital. Last year, we had the Outram Inquiry into West Suffolk Hospital. In 2020, the James Inquiry into Ian Paterson. And, before that, Morecombe Bay, Gosport War Memorial, Mid Staffordshire, Liverpool Community Health, Winterbourne View, Anthony Ledward, Stoke Mandeville, Bristol Royal Infirmary and so on.
As Taylor says, these reports teach us clinical failure usually has an institutional setting and that blaming individuals overlooks working ‘culture’. They have also led to: (a) new regulatory bodies to manage, investigate and improve NHS standards, (b) new codes of conduct to mandate reporting of serious accidents—backed up by the Whistle-blower’s Act and explicit statutory duties of disclosure, (c) root cause analysis to encourage consistent investigations so we can learn from reliable data and (d) new ‘Speaking Up Guardians’ and a Patient Safety Commissioner to encourage informal discussion about patient safety.
What is so surprising is how little these inquiries and reforms have achieved on the larger scale. Of course, we must …
Footnotes
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Commissioned; internally peer reviewed.
Read the full text or download the PDF:
Other content recommended for you
- Relationship between labour force satisfaction, wages and retention within the UK National Health Service: a systematic review of the literature
- Culture, compassion and clinical neglect: probity in the NHS after Mid Staffordshire
- Culture and behaviour in the English National Health Service: overview of lessons from a large multimethod study
- ‘Speaking Up’ for patient safety and staff well-being: a qualitative study
- Lean management systems: creating a culture of continuous quality improvement
- Organisational values of National Health Service trusts in England: semantic analysis and relation to performance indicators
- Application of root cause analysis on malpractice claim files related to diagnostic failures
- Review of alternatives to root cause analysis: developing a robust system for incident report analysis
- Clinical-scientist-led transoesophageal echocardiography (TOE): using extended roles to improve the service
- Capacity of English NHS hospitals to monitor quality in infection prevention and control using a new European framework: a multilevel qualitative analysis