The NHS needs a culture change to deliver safer care

The avoidable deaths of babies and mothers in Shrewsbury and Telford Hospital Trust’s maternity services are heartbreaking. What makes them a scandal, however, is that the problems have been known about for so long, and yet the instinct of managers was to deflect and minimise.

The Healthcare Commission, a forerunner to the Care Quality Commission, was concerned about injuries to babies in the trust’s maternity units as long ago as 2007. It was not until Rhiannon Davies and Richard Stanton insisted on answers about the death of their baby Kate in 2009 that the Parliamentary and Health Service Ombudsman concluded in 2013 that it had been the result of serious failings in care.

Continued pressure from Davies and Stanton and other parents eventually prompted Jeremy Hunt, the health secretary, to order an independent investigation in 2017. That inquiry was widened as more cases of substandard care came to light, and The Independent has now obtained a copy of its interim findings.

Those findings are damning, revealing a pattern of failing to learn lessons, of covering up rather than coming forward. That pattern is chillingly familiar from a series of terrible cases of poor NHS care – a roll call of shame that includes Mid-Staffordshire, Gosport War Memorial Hospital, Morecambe Bay, Southern Health and the Bristol children’s heart scandal.

In every case, managers responded to concerns from patients, patients’ families or staff by dismissing failings, if they were admitted at all, as one-offs. Promises to learn lessons were generally insincere, and internal investigations too often sought to protect and excuse those responsible for errors. The interim report on Shrewsbury and Telford Hospital Trust condemns a lack of transparency, honesty and communication with patients and their families that goes back four decades.

This culture was laid bare in 2013 by the public inquiry into the Mid-Staffordshire scandal, and both Mr Hunt and Matt Hancock, his successor, have said many of the right things about changing it. The whole National Health Service needs to shift to a culture in which complaints and whistleblowing are welcomed as a way of improving care. In which managers are praised and promoted if they take lessons from mistakes and failings to develop protocols to prevent them recurring. In which patients and their families are treated with respect and as a valuable source of feedback.

This requires visionary leadership at all levels of the NHS, and it also requires two simple steps for which The Independent is campaigning.

First, whoever is health secretary after the election should require the NHS, by law, to involve patients or their families in investigations of incidents. Undergraduate training for medical, nursing and midwifery students also needs to devote even more attention to learning how to deal with clinical errors.

Second, we call upon the health secretary to restore the £8.1m funding for NHS trusts across England as part of a Maternity Safety Training Fund which helped 30,000 staff improve safety in 2016. Despite a positive evaluation, this has been cut.

The NHS is one of this country’s proudest achievements. The ideal of free healthcare at the point of need is inspiring, noble and right. But the service will not survive, and will not deserve to survive, if it cannot change its culture of patient safety. It has to become a learning, self-critical and open environment of constant improvement. The families who have suffered from the cruel neglect of Shrewsbury and Telford Hospital Trust deserve nothing less.