Safety Critical Industry – Are you different to the NHS (Lucy Letby)

Oh I agree.

Why are babies suddenly dying at this rate, what do we know about them?

What’s the normal rate though? On the news this morning 4000 was mentioned as being looked into, presumably that’s all the deaths and complications over the past few years? 10-20 in 4000 might not stand out?

What’s the normal rate though?

https://www.coch.nhs.uk/media/191064/Papers-Board-of-Directors-26th-July-2022-WS2.pdf

A bit of light reading. Ive just done some very quick googling and it was roughly 45 births per week for Chester. So I would say unexpected / unexplained deaths would easily stand out.

Doctors are scientist by nature so they do constantly review data and performance. Governance process within a Trust should then act to prevent either a clinician or a manager from covering up poor practice, but unfortunately the reality is that only the doctor is regulated.

unexpected / unexplained deaths would easily stand out

agreed, that does not mean that the reasons for those deaths are easily uncovered. How many units are there in the country? I confidently predict that 5% of them will be in the 5th percentile for high death rates in a given time period.

Here’s an interesting read for anyone interested, published last autumn:

https://rss.org.uk/RSS/media/File-library/News/2022/Report_Healthcare_serial_killer_or_coincidence_statistical_issues_in_investigation_of_suspected_medical_misconduct_Sept_2022_FINAL.pdf

Thought I’d give the full url as it is informative of content. Royal Statistical Society report:

Because suspicions about medical murder often arise due to a surprising or unexpected series of
events, such as an unusual number of deaths among patients under the care of a particular professional,
this report will begin (in Section 2) with a discussion of the statistical challenge of distinguishing event
clusters that arise from criminal acts from those that arise coincidentally from other causes. This analysis will show that seemingly improbable patterns of events (eg apparent clusters, rising trends, etc.) can often arise without criminal behaviour and may therefore have less probative value than people assume for distinguishing criminality from coincidence.

On the news this morning 4000 was mentioned as being looked into, presumably that’s all the deaths and complications over the past few years? 10-20 in 4000 might not stand out?

I thought the 4000 was the babies she had looked after – not deaths

TBH, there are statistical tools that will highlight smaller trends than that in much larger populations, but they are dependent on accurate data that is input properly and analysed by people who are *looking* for issues.

They also need buying and managing properly.

It sounds like the Trust behaved appalling and opportunities to save babies lives were missed. That would be unforgivable. The interview with the consultant on R4 this morning was interesting. He said he was not a whistle-blower, he had no concerns about escalating concern etc. Nothing wrong with policy, just a trust that refused to take action.

I am confused about the role of the consultants though. All seven of them decided that their concerns were so great that the police should be involved. The trust refused to do so, why did they not then go directly to the police?

All seven of them decided that their concerns were so great that the police should be involved. The trust refused to do so, why did they not then go directly to the police?

cowardice and its against their code of conduct not to report to the police.  Its been watered down a bit and many folk forget – but a medical practioners primary loyalty is to the patients.  A doctor or nurse who accepts an instruction from management that puts patients at risk of harm is in clear breach of professional standards.

I have used this to refuse instructions from management.

but a medical practioners primary loyalty is to the patients.

IIRC the primary loyalty of anyone working in NHS or HSC, regardless of role is set out as the patient, client or service user.

yes. and we all have a duty to report crimes ( so long as the breach of confidentiality incurred is worth it ie a minor crime you might not report but anything putting someone at risk you must report)

What’s the normal rate though?

From the BBC article

Before June 2015, there were about two or three baby deaths a year on the neonatal unit at the Countess of Chester Hospital. But in the summer of 2015, something unusual was happening.

In June alone, three babies died within the space of two weeks.

Statistically it could happen. But concerns were raised at that point

The deaths were unexpected, so Dr Stephen Brearey, the lead consultant at the neonatal unit, called a meeting with the unit manager, Eirian Powell, and the hospital’s director of nursing Alison Kelly.

Everything after that is a fail, in the sense that action could have been taken but was not. You can argue that the first three in quick succession couldn’t be prevented; if a nurse wanted to do the same again tomorrow then it would be very hard to stop.

A doctor or nurse who accepts an instruction from management that puts patients at risk of harm is in clear breach of professional standards

I look forward to reading about the GMC hearings into the doctors who did follow those instructions and the doctors in management who issued them. I’m not going to hold my breath because I very much doubt the GMC will do anything

The reviews were looking to see if there was evidence of clinical incompetence not a murderer.

That’s not unreasonable. Medical murderers are fortunately rare. Clinical incompetence unfortunately is not.

Looking for clinical incompetence is not the same as looking for evidence of crime, so it’s not surprising that the reviews didn’t turn anything up.

I was thinking about this earlier today.  I’m sure there is a similarity to sex abuse in the churches, at first it seems implausible that someone in that profession would want to harm others so alternative explanations seem much more likely.  Bent cops are probably similar.  To really put your head above the parapet you need not only to be morally right, but to be financially secure.  Current protections don’t go anywhere near enough to protect those who could be morally more robust if they could afford to be.  There are very few people at the top who are measured on “discovered and reported a crime” so it’s not the culture that cascades down.

most organisations (and this includes the nhs in Scotland despite TJs rose tinted glasses) have an immediately defensive response to anything vaguely resembling a complaint.  I also think in Scotland we have a very limited view of fatality investigation.  My gut feel is coroners may be better than the PF.

Treat with great suspicion anyone who says it could never happen in their organisation.  There’s always the potential for a screw up, and that means there’s always someone who will have an interest it covering it up.  Consciously or subconsciously people with malevolent intent will exploit those weaknesses.

most organisations (and this includes the nhs in Scotland despite TJs rose tinted glasses) have an immediately defensive response to anything vaguely resembling a complaint.

not always and the culture is changing but I tend to agree.  I did not mean to give the impression I thought everything rosy up here – its just I know the Scots NHS procedures but I am not certain on the English ones

However the setup up here does remove one driver of the behaviour that causes the secrecy – the collaborative nature which means hospitals are not in competition

I am still in favour of “no fault” incident investigations as being the only way to discover the truth

There is the behaviour of assigning fault in everything. People don’t want reviews and investigations because they are about finding out who messed up not what went wrong. The latter will/may pick up who messed up if that’s the case but there’s a lack of honesty if everyone is worried about how they will be affected.

People don’t want reviews and investigations because they are about finding out who messed up not what went wrong.

Actually from my understanding is most folk want to know why the incident happened and that it will not happen again.  they generally do not want an individual punished.  Its very rare in medical incidents that there is a single action that causes it.

but there’s a lack of honesty if everyone is worried about how they will be affected.

Which is why “no fault” needs to be the way forward

https://www.england.nhs.uk/patient-safety/incident-response-framework/

So this is English governments attempt to solve the issue. It was a top down instruction from central government about a year and a half ago, with tight deadlines for implementation. We all wondered what the trigger was at the time, and there was some ‘gossip’ as to what was behind it.

Some Trusts are still struggling to implement it now. Others have implemented it, but culture prevents it being effective.

Lots of talk about culture, yet to read one suggestion on how you actually start to tackle it.

There’s an utter lack of transparency even internally, so no surprise that influences a toxic culture of blame & retribution. That in part is due to how HR personnel are bred via the CIPD, they’re a threat to any kind of just culture. They should IMO be removed from any investigation loop.

It’s why nothing ever changes, from an outsider’s perspective people are scared because it would involve making very bold changes which would be unpopular.

As a result things will get much worse before they get better. We can cry about Tory underfunding but the organisation will be destroyed as a result of its own behaviour before privatisation.

I have – “no fault” incident investigations.  that allows folk to be candid s they should no ;longer fear disciplinary for genuine mistakes

also get rid of the fake market in England which produces pressures to be secretive by seniors

I have – “no fault” incident investigations. that allows folk to be candid s they should no ;longer fear disciplinary for genuine mistakes

As is the way, an easy statement to make. Do you have any idea how you implement, enforce and assure such a thing?

I’d lift the MAA model a drop it on the NHS in a heartbeat, but it doesn’t like outsiders so would be unpopular, challenging and costly.

All the reasons why it would never happen.

Better training for managers as well.

also get rid of the fake market in England

That already happened some time ago. (about 2017 under the Stevens reforms)

Sorry and another edit: The payment for results (provider/commisioning) stopped in about 2019 or so.

its still there in principle is it not ie hospitals / trusts act as quasi autonomous and compete for resources?  Certainly I have read in the commentary about the letby case that this issue leads to a culture of cover up

“no fault” incident investigations. that allows folk to be candid s they should no ;longer fear disciplinary for genuine mistakes

It’s frustrating to read this as an outsider to the health industry. That people are still fearing disciplinary proceedings for genuine mistakes is a massive problem in 2023.

FWIW, aviation moved from “no blame” to “just culture” some time ago. This is different in that it acknowledges that human errors can occur even in well-designed systems. There may be instances where individuals need to be held accountable for their actions if they demonstrate wilful negligence or consciously disregard safety protocols. This approach seeks to strike a balance between encouraging reporting and learning, and ensuring that individuals are responsible for their actions when they knowingly violate safety procedures.

To put the difference in monitoring into perspective, if you take a flight in the UK the contents of the “black box” (simplifying a bit here) will be downloaded wirelessly to the airline’s HQ before you even get through the terminal. This is then automatically analysed and anything unusual will be flagged up (there are thousands of parameters and triggers). This then reviewed by another line pilot who is emphatically not management.

Outside of this system, every single flight finishes with a discussion about what happened and what can be improved upon.

Trends from this automatic analysis are identified and then directly targeted during six-monthly training cycles. We have two safety magazines published each month. Airbus have an enormous publicly accessible training library packed with videos. We have free access to the full flight simulators during off-hours.

As many others have highlighted the biggest problem in the NHS seems to be a culture of trying to protect the Trusts from admitting any error. I can actually completely understand this as an admission of error usually leads to legal action and as someone who was called as a professional witness a few years ago in a High Court case, it’s a deeply unpleasant affair that I’d prefer not to go through again. Whether or not this has to be accepted as part of the job of working in health, I don’t know.

I believe ( and think the resrearch backs this up) that actually most folk do not want legal action and huge compensation – they want candor about what happened and an understanding that steps will be taken to prevent it happening again

the omerta actually encourages folk to sue as its often the only way they get answers

its still there in principle is it not ie hospitals / trusts act as quasi autonomous and compete for resources?

No it hasn’t been like that for ages. The Provider/Purchaser split was a disaster from the get go (Landsley 2012)  I don’t think there’s been legislation to actually take it off the the statue, but Stevens in 2017, and the long term plan in 2019 pretty much killed it. The only thing left is NHS Property I think

Certainly I have read in the commentary about the letby case that this issue leads to a culture of cover up

The first cases happened waaay back in 2015, so possibly that may have been the case then?

I raised a safety issue within the cycling industry, and got nothing but grief from many cyclists (especially on here), as well as being fobbed off by the relevant authority in open collusion with manufacturers.

So yeah, I can believe that such attitudes are widespread. It’s not really about “people in power”, it’s about people who aren’t prepared to face difficult decisions, don’t like having their equilibrium disturbed.

Certainly I have read in the commentary about the letby case that this issue leads to a culture of cover up

Do remember that the Letby murders were in 2015 and 2016. What was the case / in place then may have changed 7 or 8 years later (IDK and have suspicions of course)

So it’s entirely possible that some of the desire to not admit to failings, driven by quasi-competition, etc., may not be as strong now.

And back to ‘no fault / no blame’

As i said previously, I don’t like that phrasing. I get that people should be unafraid to raise failings and know they will not be automatically penalised for raising it, or unfairly scapegoated without listening to mitigations, etc. But if things happen because people do things wrong, whether by intent or incompetence, then they need to be accountable and dealt with properly. If that’s eg: lack of training to perform a task then the cause is the lack of time / funding / recognition that training is needed, which is a failing by management. If it’s wilful that they know how to do it and cut corners or whatever then that’s on the person. It’s not a free hit which ‘no fault, no blame’ makes it sound like. Doesn’t mean that the book has to be thrown either, perfectly possible to have a review that identifies where the fault lies, maybe there is a sanction, but learnings are taken from it.

Honest mistakes should not mean disciplinary action.  thats the crux.  Its almost never one mistake anyway.

Do you want to prevent further incidents?  In which case we need the facts given honestly.  If people think they are going to be punished they will not be candid

What happens right now is folk slant their evidence and point the finger at each other.

Also, reputational damage is still damage. If folks with disease or need urgent care aren’t coming to the hospital because they perceive it to be unsafe, not great care or whatever, then that’s going to be bad for local healthcare. It’s not an “at all costs” thing that needs to be the only thing senior management team care about certainly, but it absolutely should be something they consider and take care to try to protect. Whole Hospitals are rarely bad, it’s more than likely going to be individual depts within the whole, but once ‘word’ gets out, it’s difficult to be nuanced about it.

I am still in favour of “no fault” incident investigations as being the only way to discover the truth

criminal investigation seems to have got something resembling the truth.  Now if others have helped cover that up should they be blameless in any “how did we not spot it sooner” investigation?  I think most people would struggle with that.  And that is the problem with Rail/Marine/Air accident style investigations, their focus is on preventing recurrence with the premise being that it was “an accident”, nobody intended it and everyone learning is better than trying to blame one person.

I’m not convinced that competition encourages cover ups either.  The organisations least open to critique in my experience are effectively monopolies, especially those held in very high esteem by the public.  Usually doing some “worthy” thing, and criticising the organisation is treated as saying the worthy thing they do is wrong.  Genuine competition means incompetent organisations will often fail.  Even the worst run NHS trusts don’t truely fail – the hospitals and staff don’t close.    To be 100% clear I am not advocating for privatisation, but we should be aware that when a public service (schools, hospitals, fire services, police forces) are unable to fail they can become pretty toxic.  Whilst the organisation can’t fail the individuals can and that’s where the self preservation culture stems from.  Promotion comes not from finding the bad actors in the system but from outwardly presenting an image that everything is under control.

Do remember that the Letby murders were in 2015 and 2016. What was the case / in place then may have changed 7 or 8 years later (IDK and have suspicions of course)

I don’t mean to pick on you particularly, but it’s a convenient jumping-off point. This attitude gets trotted out time after time and it’s just such a heap of stinking bullshit. People don’t change, not much anyway, and behaviours get repeated time after time. We had it all with miscarriages of justice. “Oh, that was the 1970s, it was all different back then”. “Oh, that police rapist was last year, we’re different now”. “Oh, back in the 1800s everyone thought slavery was just fine, we’re more evolved now”. 2015 is hardly the Dark Ages.

Ok, we did eventually outlaw slavery (after a century of campaigning). Change does happen, but it’s slow and gradual and while so many people willingly acquiesce to abuse of power, abuse of power will continue.

A culture change is needed.  IMO the no fault incident investigations are the key component in doing so.

It does not help that I have known a number of nurse managers who are totally ill informed in this sort of area and put the frighteners on the staff telling them they will be personally liable when actually they would not be

Better manager training is a key thing as well

Better manager training is a key thing as well

‘Some’ management would be a good place to start frankly. I don’t know of any organisation quite like the NHS that has so few (and ill trained) managers in it.

So if you want truthful evidence and that evidence points to a failing, do they get off scot free because they raised it? I don’t agree.

Hypothetical situation – a nearly serious incident where someone was working with solvents in a controlled space (ie behind access controlled doors with no people just coming and going)

The policies and procedures made it clear that when undertaking hazardous activities in this space (where RA shows residual risk > whatever) then user must not work alone. However it was manager discretionary what that meant – didn’t mean the person had to have a second stood over them, could eg: have a open video call that someone external could view.

The worker set this up, but then also deviated from the experimental process and raised the lid of fume hood above working level because it was easier to access the kit. They were then overcome by fumes, sufficient to need medical care but not so bad they weren’t able to raise alarm for themself.

Their overwatcher had gone off to make a cup of tea, got sidetracked on the way back and missed all the excitement.

This was investigated fully, and there were several failings leading to reprimands for the overwatcher (if you’re given that job, do it properly) and in a formal warning (don’t cut corners to save time, follow the process!). The only actual change made as a result is to interlock the fume hood to not allow it to be opened beyond the safe level. The rest was sufficiently robust procedures that folk just didn’t follow, and consequently got ‘punished’ – rightly.

So it’s not easy – if they’d known they’d get reprimands for this would they have raised it. It wasn’t possible to cover up completely in this case because first aiders/hospital visit, but how serious the outcome was was only luck once the incident happened. Could have been more severe, equally could have been ‘whoa, I went light headed there…..but my own stupid fault, better not tell anyone, lesson learned, put the lid down properly eh!’

There are two separate issues here I think – Risk management vs illegal acts by an individual

Safety and risk management – healthcare has a lot to learn from other industries. I’ve worked in a few (chemicals, pharma and now medical devices) where the structured risk assessments and continuous learning/improvement could and should be applied to healthcare. Healthcare (and mainly consultants) seem to think they are some unique and special flower that can’t learn from any other industry. A level of honesty is required about deaths and incidents, some will happen, saying there should be zero is unhelpful you can’t apply a lot of risk management tools with zero, probability doesn’t work like that.

Willful illegal acts are something entirely different – these safety systems aren’t set up to deal with that really. When working at a large chemical site with a very good safety record, one disgruntled employee sabotaged part of the plant (undid a pipe) and ended up spraying a colleague with caustic. All the risk management – design reviews, commissioning tests, scheduled maintenance…) couldn’t prevent that

So if you want truthful evidence and that evidence points to a failing, do they get off scot free because they raised it? I don’t agree.

Depends on the failing.  A punative approach does not work.  To continue to do the same thing and expect a different outcome?

the failing may require nothing, it may require retraining, if a criminal threshold is reached then obviously prosecution

what should not happen is honest mistakes leading to disciplinary

its still there in principle is it not ie hospitals / trusts act as quasi autonomous and compete for resources?

In theory no. But the culture still very much intrenches this. Integrated Care Systems (ICS) have been setup to replace CCG’s which were PCT’s

The approach now is that we all share the love in a region ie we all work for the local population in the area. In our area this means some Trusts inherit other Trusts poor financial positions, which means they cannot spend where needed. Its currently creating more division and silo working in our corner of the world as Trust try to protect their own autonomy. I doubt its different anywhere else.

I believe ( and think the resrearch backs this up) that actually most folk do not want legal action and huge compensation – they want candor about what happened and an understanding that steps will be taken to prevent it happening again

the omerta actually encourages folk to sue as its often the only way they get answers

TJ – yes certainly in the only case where I’ve complained the aim was never compensation. The aim was that they make the treatment better for the next person.  I don’t actually know if we succeeded because a lot of the response seemed to be about wearing you down until you give up, as well as telling me things didn’t happen I saw with my own eyes.  It did get so frustrating that they were covering up what happened that it did make us think maybe we do need to sue them to get the attention this deserves.  (FWIW this should have been a 10 minute debrief – how could we have made that better for this patient?  Nothing they needed to do would have cost money or needed more people – they just needed to take a deep breath, take a step back and remember there’s a person lying on the bed.). In the end someone realised I wasn’t chasing a claim and promised to review their approach – no idea if they actually did

‘Some’ management would be a good place to start frankly. I don’t know of any organisation quite like the NHS that has so few (and ill trained) managers in it.

Agreed. A 1 hour interview isn’t sufficient. Better training (mandated) to be an essential criteria at application apply for management roles would be a good place to start.

The MAA investigation model is top drawer and would provide the much needed transparency and assurance they would ensure accountability and responsible and fair outcomes. With an assurance framework to enable investigations to stand under scrutiny.

The other reason I raise it is because unlike their civilian counterparts military aviation does look at criminality as part of the process. So if there is deliberate nefarious acts then suitable action can take place. The NHS just culture approach does the same.

Some you you are applying your own subjective interpretation of what TJ is saying, he’s saying no fault investigation the outcome and fault/blame/accountability should come as a result of an open and impartial investigation. That requires independence and autonomy, something staff investigating within their own trust do not truly have.

Errors, such as those flagged on DATIX should be shared widely. Yes, it’s uncomfortable but a lack of transparency creates ambiguity, ambiguity can be exploited and/or create conditions for mistakes to thrive.

The organisation is institutionally disingenuous and as another poster has said, excuses have to stop being made.
Someone who failed to do their job in 2015 is unlikely to have changed their behaviour.