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Over 10 years ago I was chatting to an NHS manager who mentioned that a major NHS scandal was about the break and warned me to brace myself for the worst.
A few days later, news of care failings at Mid Staffordshire NHS Foundation Trust was all over the media. As I listened in horror to the testimonies of people whose relatives died, I clung to a hope that this would be the scandal to end all scandals.
“Care failings have continued to be reported”
When the Francis report on the inquiry that followed was finally published in 2013, it suggested the problems at Mid Staffordshire were not isolated to the trust and the recommendations could lead to lasting change across the NHS.
However, in the intervening years care failings have continued to be reported – Winterbourne View and Morecambe Bay among others. We have watched politicians and NHS leaders shake their heads, try to explain and promise that lessons would be learned – but failures in care keep happening.
Last week, the Independent newspaper published the findings of a leaked report on maternity services at Shrewsbury and Telford Hospital NHS Trust. The report looked into the deaths of 42 babies and three mothers, and the management of more than 50 children who suffered brain damage as a result of oxygen deprivation during birth between 1979 and 2017.
The details are shocking and the author notes the now-familiar causes of failure – poor communication and a lack of transparency with families, failure to identify and learn from mistakes, and last but not least a culture “that is toxic to improvement efforts”.
Commenting on the story in Nursing Times, Dr Aled Jones, a professor of patient safety at Cardiff University, said the frequency and similarity of these investigations were “telling” and “sobering”.
He highlighted that the first report into care failings in the NHS – at Ely Hospital – was published 50 years ago but “you can cut and paste recommendations from that [Ely] into every subsequent report around failures of the NHS”.
Why are wider lessons not learned from these awful situations? A spokesperson for the Royal College of Midwives told Nursing Times that it was important that the trust learned from these failings.
Of course, the individual organisation needs to change, but other NHS trusts need to look at their services through the prism of the leaked findings. The report’s focus on a single organisation makes it easy for others to assume the failings it documents could never happen on their patch, and consequently that it is someone else’s problem.
“How do you achieve a meaningful, positive patient-centred culture that is consistent across the NHS”
It is clear that when organisations lose sight of patients as people, bad things happen. The question is, how do you achieve a meaningful, positive patient-centred culture that is consistent across the NHS?
How do you ensure standards of care are maintained in underfunded and understaffed wards where just managing to get the basics done is an achievement? How do you maintain staff wellbeing when arranging time off for mandatory updates is a struggle and attending a Schwartz round or clinical supervision session is nothing more than an aspiration?
I wish I had answers, but I think we all have to keep asking these questions or we will be here again in 10 years’ time.
Looking back at Ely Hospital, one former resident said “We must never forget… it was a terrible place”.
How many times since Ely have governments and NHS leaders promised to never to forget – and then promptly forgotten?