Medical negligence - Lessons not learned

Medical scandals are nothing new.

The first modern inquiry into failures in NHS care dates back nearly 60 years, to the launch of an investigation into allegations against staff at Ely Hospital in Cardiff, in 1967.

Others go back even further, and the NHS is not unique in its responsibility for medical mistakes and malpractice. Private hospitals and healthcare providers are not immune.

Over the years, the names associated with many of the most significant NHS scandals have been etched on the national psyche: Thalidomide, Alder Hey, Infected Blood, Stafford Hospital, Dr Harold Shipman.

But these are just some of the most notorious. There have been many more. The circumstances and locations may vary, but one recurring thread is the time it takes for any action or policy change to be made.

Mistakes will always happen, of course. But the failure to capitalise on the insight, learn from the past and improve the delivery of care, is a common theme that plagues the NHS.

Pattern recognition

The story of lessons not being learned around healthcare failings will be familiar to anyone who practices in clinical negligence, almost anywhere in the country.

At a recent Law Society Gazette roundtable discussion sponsored by ARAG, panellists from diverse parts of the clinical negligence world, including claimant and defendant lawyers, expert witnesses, an insurer and a birth trauma charity, all acknowledged the grim reality that tragic mistakes are repeated, time and time again.

Sometimes, the fragmentation of the NHS and, to a lesser extent, private healthcare provision is cited as a contributory factor in the repetition of often terrible medical malpractice.

Certainly, the litany of maternity scandals scattered around the country all shared from a list of familiar failures. Inadequate training, shortages of staff and equipment, cultures of denial, bullying, secrecy and cover-up have been revealed in report after report, over decades.

At Morecambe Bay, Northwick Park, East Kent, Cwm Taf, Shrewsbury and Telford, Nottingham University... if individual trusts were shown not to have learned from their own mistakes, what hope could there be for improvement at a national level.

But fragmentation cannot be blamed when mistakes are repeated, over many years, in the same trust or hospital.

Knowledge sharing

Even when knowledge is shared, there is no guarantee that it will be assimilated. One clinician who was among the guests at the roundtable spoke of still seeing the tragic results of not following specific clinical guidance that was issued to maternity units more than a decade ago.

Even now, after the publication of last year’s Birth Trauma Report, among many other reviews and recommendations, there seemed a sombre resignation around the roundtable that imminent or rapid improvement seemed unlikely.

One expert suggested that, for maternity units in particular, the sheer volume of guidance was hampering progress. Staff have been so inundated with improvements that it simply isn’t possible for already underresourced departments to heed them all. A form of ‘improvement fatigue’ may have set in.

A lesson in politics

At another level, there is also learning for legislators to do. For many years now, successive governments have looked hard at the question of claimant costs and how to reduce them.

Despite the failures of numerous predecessors and the unavoidable truth that cutting legal costs can only ever address a fraction of the financial bill and none of the physical, emotional and social cost, it still isn’t clear that politicians understand that the prize lies elsewhere.

If they do understand it, maybe the returns on the investment needed to address those recurring issues are just too distant to have any political value.

Perhaps the only bright spot amongst all this gloom is that the opportunity to save both money and heartache is too enormous to ignore.

If only we can learn the lessons.