Summary
How is it possible to ensure that NHS Trusts learn from their mistakes? In this blog, Trevor Stevens, member of Making Families Count, explains how he intends to go about it.
Content
An outsider like me is incredulous that the NHS seems unable to learn from past mistakes. For years we’ve been hearing that lessons will be learned. Yes, we’ve made mistakes but we’re going to do better. When I hear this I think, isn’t it about time the future became the past?
Instead of hearing “We will learn the lessons from these mistakes,” I want to hear “We have learned lessons from our mistakes, and we have changed.”
It seems to me, dare I say it, like common sense. I don’t understand why it hasn’t already happened. It appears the NHS doesn’t want to change. Why not? Perhaps the answer lies in what I’ve heard the Ombudsman say on several occasions, that the NHS prioritises organisational reputation over patient safety. Cue yet more incredulity. If that is indeed the case, then I don’t fancy my chances of helping the NHS learn lessons. But I will give it a go.
Imagine your loved one died in the care of the NHS and this could have been prevented by the NHS Trust to whom they had turned to in despair, believing that the NHS professionals were the best people from whom to seek help. You know the Trust has displayed negligence in looking after your child, and you discover subsequently that your case is not the only one.
It gradually dawns on you that you have not been uniquely catastrophically unlucky, as you were convinced in the immediate aftermath of your child’s death (surely this has never happened before?), merely that you were among hundreds and hundreds of people who were equally unlucky. Unlucky to have had a child who was a service user (that’s NHS jargon for patient) of that particular NHS Trust. To your surprise the Trust admits that your child’s death was preventable, admits that it made many mistakes and doesn’t try to hide the fact. They involve you in the investigation process and keep you informed of progress. They apologise, both in writing and in person.
You will not be surprised to know that this hypothetical dilemma is not hypothetical for me. In my case it was my daughter's suicide. When my daughter took her life, I was tempted to join the calls for a public inquiry and the demands for a criminal investigation into the Trust that failed my daughter. Many people feel it is the right thing to do. But I ask myself: how long does an inquiry take? Two years? Three years? Seven years, as in the case of the Infected Blood Inquiry, set up in 2017 and only just reported?
I’m 66, I can’t afford to wait that long. I want to see results. As the Health Foundation says: “we pay too little attention to what happens after an inquiry has reported” and we need to make sure “the report is not the end of the inquiry, but the start of a process of meaningful change and reform”.[1]
Yes, an inquiry, when it eventually reaches its conclusion, publishes its findings and gives its recommendations, should be the beginning not the end. I’m not sure this is often the case. The public switches off at that point. They emit a sigh of relief. Rarely does it take an interest in the hard work that follows.
I have decided to take a different route. I decided to work with the Trust to help them reduce the number of future preventable deaths as soon as possible, starting now. I always say that I will die a little less unhappy if I can save one life by telling my daughter’s story. But who should I tell my daughter’s story to? In my view I have more chance fulfilling my aim if I tell it to those who work on the frontline with young people. It’s about changing attitudes and behaviours. After all, there’s no guarantee an inquiry will be a beginning of a process of public transformation and not just the end of a public conscience cleansing. And I might be dead before it provides its recommendations. I reckon I’m more likely to see success if I work differently. How much more likely, I don’t know, but I’ll find out.
I don’t want to hear that what I’m doing will help to save a life. I want to hear that it has saved a life. I want to hear people say: “Instead of doing what we did last time, which failed to keep patients safe, we are now doing this. And you know what, it works. I can show you.”
How hard can it be? I want my daughter’s death to be the beginning, not just the end. And I want that beginning to start as soon as possible. The future needs to become the past.
Reference
Further reading on the hub:
- Lessons not learned: A family's lengthy efforts to turn complaints into improvements
- The hospital told me to GO HOME, but my daughter was critically sick. A bereaved mother’s 11 patient safety lessons
- Patient Safety Spotlight interview with Rosi Reed, Development and Training Coordinator at Making Families Count
- Patents who experience harm provide stories, but who will really engage with their insights and opinions?
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