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The PHSO report is now available
The National Health Service is suffering from a deficit of accountability and compassion for patients and their families when things go wrong, England’s Health Ombudsman has warned.
In a new report, ‘Broken trust: making patient safety more than just a promise’, the Ombudsman has said the NHS must do more to accept accountability and learn from mistakes, particularly when there is serious harm or, worse, loss of life.
When concerns are raised after such incidents they are too often met with a defensive attitude. This makes things even worse for a grieving family trying to get answers. It also places unnecessary pressures on staff, creating a barrier to learning and a gateway to making the same mistakes.
Despite significant progress made on patient safety in the last decade, ten years on from the Francis inquiry into failings in care in Mid-Staffordshire, we are still seeing too many preventable tragedies. The Parliamentary and Health Service Ombudsman (PHSO) considered over 400 serious health complaints from the last 3 years and found 22 cases of avoidable death.
The Ombudsman has called for urgent action from the Government to prioritise patient safety and protect families who search for understanding in the wake of a tragedy.
The report sets out recommendations to improve patient safety. These include:
- better support for families affected by harm
- embedding cultures that promote honesty and learning from mistakes
- getting the right oversight and regulatory structures to prioritise patient safety
- and an evidence-based and long-term workforce strategy that has cross-party support.
Ombudsman Rob Behrens said:
“Mistakes are inevitable. But whenever my office rules that a patient died in avoidable circumstances, it means that incident was not adequately investigated or acknowledged by the Trust.
“Every time an NHS scandal hits the front pages, leaders promise never again. But the NHS seems unable to learn from its mistakes and we see the same repeated failings time and time again. Our report looks at the reasons for the continued failures to accept mistakes and take accountability for turning learning into action. We need to see significant improvements in culture and leadership. However, the NHS itself can only go so far in improving patient safety. One of the biggest threats to saving lives is a healthcare system at breaking point.
“The Government says patient safety is a priority but, if it means this, the NHS must be given the workforce capacity it needs. We need to see concerted and sustained action from Government to support NHS leaders to prioritise the safety of patients. Patient safety must be at the very top of the agenda.”
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Source: The Office of the Parliamentary and Health Service Ombudsman, UK
