‘Defensive culture’ hindering timely patient safety investigations, MPs told

A culture of defensiveness, avoidance, complacency and denial in the health service is hindering patient safety issues being investigated in a timely manner, MPs have been told.

There have also been calls for probes to be carried out by trained professionals, rather than as an add-on to someone’s day job.

The comments were made in a Health and Social Care Committee evidence session as part of its probe into NHS leadership, performance and patient safety.

Miles Sibley, one of the founders of the Patient Experience Library, spoke about delays in patient safety issues being investigated.

He told MPs: “I can’t talk for inquiry processes, but in terms of the time it takes for these things to come to inquiries, I think partly it’s because of these cultures of avoidance and complacency and denial and cover-up. Foot dragging is a tactic.

“And when you read inquiry reports, you see examples of this all the way through, again, things like case notes being mysteriously lost. It’s a tactic.

“And you can go right to the start of this where people start to raise concerns and find that hitting a brick wall almost straight away.”

Dr Jayne Chidgey-Clark, National Guardian for Freedom to Speak Up at the National Guardian’s Office,  also told MPs she thought that in some cases, the decision to carry out an inquiry can take too long.

“I think the defensive culture can get in the way of people giving the evidence in a meaningful time.”

However, she added “we know the extreme pressure the NHS is under”, and that “can impede” on this.

Dr Chidgey-Clark said she read Sir Brian Langstaff’s 2,527-page report from the Infected Blood Inquiry, which explored the circumstances in which more than 30,000 people were infected with deadly viruses between the 1970s and early 1990s as they received blood transfusions or blood products while receiving NHS care, with “deep dismay”.

Sir Brian’s probe into what has been described as the worst treatment disaster in the history of the NHS was ordered seven years ago by former prime minister Theresa May.

He concluded that deliberate attempts were made to conceal the disaster, including evidence of Whitehall officials destroying documents.

Dr Chidgey-Clark added: “There will be a potential to say: ‘Oh, that was back then’. But actually for the messages to the health service now around leadership and accountability, that message is for today because we’re seeing it time and time again.”

She also called for “timely investigations” to be carried out by “expert investigators who are trained in investigations”.

“Far too often investigations are done by people as an add-on to their day job who haven’t had the necessary training,” Dr Chidgey-Clark said.

Mr Sibley was asked if listening to every single patient story during a probe – rather than a representative number – could lead to delays in lessons being learned.

He said listening to “every single story” during an investigation is “actually necessary because people are hurt, harmed terribly”.

“If you look at things like pelvic mesh, life-changing injuries. If you look at deaths in maternity, people losing their babies and then encountering the further harms of cover-up and denial and all of that.

“I think people need to have ways to be heard.”

Dr Chidgey-Clark said it can be “too tempting” for bosses to box-tick in the face of many recommendations from inquiry reports.

“Having been a non-exec director in an NHS organisation as well, I know what it is like for boards faced with a plethora of recommendations out of all these reports, plus all the compliance issues,” she said.

“And it can be too tempting to focus on just ticking the box that ‘we’ve done that, we’ve dealt with it’, but not really getting under the hood of has behaviour changed at the frontline? Because that’s what needs to change.”

Dr Chidgey-Clark also expressed disappointment in the inconsistency of the implementation of Freedom to Speak Up Guardians, staff who support others in speaking out about issues.

The creation of the role was recommended by Sir Robert Francis in the Freedom to Speak Up review in 2015.

She said there is “some leeway” in how trusts implement the role, but the National Guardian’s Office does provide guidance.

“What we see is an absolute inconsistency, which is a big disappointment to me. And that inconsistency is a worry.

“Our office wasn’t set up to be a regulator. So we can’t absolutely dictate, however, we have best practice, and what I rely on is NHS England and CQC as the regulators to help enforce.”

Asked if there are enough NHS resources to allow guardians to do their role properly, Dr Chidgey-Clark replied it is “varied”.

“I very worryingly have heard of accounts from some guardians where they feel that when they’re delivering messages around themes that are hard for organisations to hear, that they feel they suffer detriment themselves, which is clearly unacceptable,” she added.