This “Learning Not Blaming” report presents the government’s response to (i) the Francis Freedom to Speak Up review, (ii) the Morecambe Bay Investigation, and (iii) the Public Administration Select Committee’s report on clinical incidents.
The common theme for addressing the challenges posed by the above reports (and by Robert Francis QC’s earlier report into poor standards of care at Mid Staffordshire NHS Foundation Trust) is to support NHS staff in raising concerns about poor care and lapses in patient safety.
The mission is to create a patient-centred (rather than a supplier-driven) NHS, which is capable of becoming the world’s largest and safest and largest “learning organisation”, with a built-in open culture which encourages continuous quality improvement.
Learning not blaming: the government response to the Freedom to Speak Up consultation, the Public Administration Select Committee report ‘Investigating Clinical Incidents in the NHS’, and the Morecambe Bay Investigation. London: Department of Health, July 15th 2015. Cm 9113.
Further clarification of the overall vision for openness and transparency in the NHS:
Jeremy Hunt: message to NHS staff about the future NHS. London: Department of Health and Rt Hon Jeremy Hunt MP, July 17th 2015.
Possibly also of interest:
How speaking up can save lives. London: BBC Health News, July 26th 2015.
On the possibility of discouraging / shutting-down an open learning culture, arising as an unintended consequence from the ruling in the case of Dr Hadiza Bawa-Garba:
Jeremy Hunt says doctors must be allowed to discuss mistakes. London: BBC Health News, January 28th 2018.
Appeal won, in the interests of future openness and transparency?
Struck-off Dr Hadiza Bawa-Garba wins appeal to work again. [London / Leicester]: BBC Health News / BBC Leicester News, August 13th 2018.
Miserable and vengeful in-fighting; a reflection of the human-condition? So much for the culture of “blame-free learning”:
Dr Hadiza Bawa-Garba: GMC boss told position is ‘untenable’. London: BBC Health News / BBC Leicester News, August 28th 2018.
Relating to more to nurses:
Full Text Link (Note: This article requires a suitable Athens password, a journal subscription or payment for access).
Law, BY. [and] Chan, EA. (2015). The experience of learning to speak up: a narrative inquiry on newly graduated registered nurses. Journal of Clinical Nursing. July 2015; 24(13-14): 1837-48.
Patient Safety: Priority in Medical Education and Training
The General Medical Council (GMC)’s “Promoting Excellence: Standards for Medical Education and Training” elevates patient safety to the top priority in undergraduate and postgraduate medical education and training.