Serious Failings in Care Revealed this Summer

It will not have escaped your notice that various very big news stories broke this summer, where serious failings in care have been reported. We have briefly summarised them below, focusing on the action being taken to prevent these failings in the future.

Nottingham Maternity Review

In July senior midwife Donna Ockenden announced that she would be investigating the cases of 1,700 families, after dozens of baby deaths and injuries at Nottingham University Hospital (NUH) NHS Trust.

This will be the largest review of maternity care ever carried out in the UK. The NHS Trust has made a full apology to all the families involved and has pledged to be open and honest throughout the investigation.

Duty of Candour

Under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 20, the NHS Trust and professionals within it owe a professional duty of candour.

This requires them to be open and honest with the people using their services and sets out particular requirements and obligations that must be fulfilled when things go wrong.

Duty of candour was a principle formulated by Sir Robert Francis, in his report on the serious failings in care at the Mid Staffs NHS Trust in 2013. It was hoped at the time that this would lead to the development of a common NHS culture of openness and transparency, which would in turn drive up standards of care, enable us to learn valuable lessons and prevent future incidents.

As you can see from the quotation above, being open and honest is also vitally important in facilitating public trust and confidence in NHS services and their ability to investigate and learn from their failings.

Learn more about duty of candour:

• Government Guidance on Duty of Candour
• CQC Guidance on Duty of Candour
• NHS Resolution: Saying Sorry

Lucy Letby

In August, former nurse Lucy Letby, was given a whole life sentence in prison after being found guilty of murdering seven babies at at the Countess of Chester Hospital between 2015 and 2016.

On the 18th August the government ordered an independent inquiry to investigate the circumstances and the wider context of NHS care and regulation.

At the beginning of September it was announced that the inquiry would be statutory (have legal powers to compel witnesses to give evidence) and will be led by a senior judge Lady Justice Kathryn Thirlwall.

Independent Inquiries

An independent inquiry is a retrospective examination of events and circumstances that led up to and surrounded a serious failing.

The first step is to gather evidence, which may be in the form of hospital data, statistics, patient records, complaints and so on. The next step is to have a hearing - where people give evidence to the inquiry (a bit like a court hearing but people are not being judged or prosecuted). The final step is the compilation of the evidence into a report, together with any findings of the inquiry (for example what happened or why it happened), and a series of recommendations (to prevent the failings from happening again).

Independent inquiries can be ordered by the government whenever a serious failing occurs within the NHS. It is called an independent inquiry because it is not carried out by the government itself, but by an independent group of people led by a chair person. The chair person will be someone of considerable professional standing and they may have expertise in either health and social care or law. Independence of the inquiry team is to ensure that findings are unbiased, accurate and objective.

The findings of the inquiry are presented to the government with the intention of informing changes in practice and policy but they should be free from political influence - they are independent of party politics.

Inquiries may be statutory, as is the case with the Lucy Letby inquiry. This means they have legal powers to request evidence and request individuals to give evidence.

Inquiries can be public - which means that evidence is heard in an open setting where the public may attend - or in private.

Statutory public inquiries are established when there is a serious case of public concern, such as in the Lucy Letby case. The UK COVID-19 Inquiry is another example of statutory public inquiry that is currently ongoing.

Martha's Rule

In September we learned that Rob Behrens, the Parliamentary and Health Service Ombudsman, supports the introduction of Martha's Rule, which would give all NHS patients or their families/carers the power to get an automatic second medical opinion about hospital care, when they think things are going wrong.

Martha Mills was 13 years old when she died from sepsis and her parents did not feel listened to when they raised their concerns and the hospital caring for Martha has since admitted to serious mistakes. Her mother Merope is campaigning for this rule to be made law.

The Conversation have looked at this proposal in depth Martha’s rule: second-opinion law can work – but only if organisational shortcomings are addressed

Parliamentary and Health Service Ombudsman

The Parliamentary and Health Service Ombudsman can investigate complaints about the NHS in England, government departments and some specific agencies, if an individual is unsatisfied with the result of a complaint they have already made directly to the organisation. The PHSO is therefore the place that service users can escalate their complaint to, if they feel that no-one is taking their complaint seriously, or taking the right action.

The PHSO has an excellent podcast you can listen to. The latest episode features Rob Behrens and Dr Bill Kirkup as they discuss patient safety. Dr Bill Kirkup has chaired numerous independent inquiries into serious failings in care, including into the maternity services at Morecombe Bay and East Kent.

Radio Ombudsman Podcast

Preventable Deaths in Young Autistic People

In September we also learned that despite warnings from coroners over the last 10 years, young autistic people are still being failed by the health and social care services. Life expectancy for autistic people is - on average - 16 years less than for the general population.

The BBC have looked through thousands of Reports to Prevent Future Deaths (recommendations made by coroners) to try and find out why - nearly half were categorised by coroners as relating to mental health or suicide.

You can read more here - Young autistic people still dying despite coroner warnings over care

The Role of the Coroner

A coroner is a special judge who investigates certain deaths. Deaths are reported to the coroner if:

• The cause of death is unnatural, violent or unknown; and/or
• The death took place in prison, police custody or another place of detention such as a mental health hospital.

The role of the coroner is to find out who died, how, when and where. They will then decide whether an investigation is required.

An investigation may involve hearing evidence and will result in recommendations being made to prevent similar deaths from happening in the future - Reports to Prevent Future Deaths.

As with independent inquiries, a coroner's investigation is not a criminal investigation, and whilst the coroner can be critical in their report, they cannot lay blame.

Reports to Prevent Future Deaths are publicly available and issued to all relevant agencies, such as NHS Trusts, NHS Improvement and so on.

Prevention is the New Cure Podcast

This is the podcast of Steve Brine, MP and Chair of the Health & Social Care Select Committee, and Prof Dame Helen Stokes-Lampard a GP.

In Episode 14, they discuss Lucy Letby and Martha's Rule, along with other health topics from the last week.