November 28, 2022
A summit of key stakeholders in healthcare in England today welcomed a new report on the need for independent advice and advocacy for people affected by avoidable harm in healthcare and called for it to be addressed. The was convened by the Harmed Patients Alliance who published the report “Signpost to Nowhere?”. The report sets out the fact that no funding is made available at all in England to ensure that patients or families affected by harm in NHS care can access independent advice and advocacy.
October 20, 2022
Action against Medical Accidents (AvMA) welcome the report of the inquiry led by Dr Bill Kirkup but expressed strong concerns about the state of England’s maternity services and renewed calls for urgent action to address concerns about safety. Read full story>
AvMA chief executive Peter Walsh said:
“The report is vindication for those women and families who suffered avoidable harm and whose concerns were initially ignored. We had the privilege of providing some advice and support to Derek Richford, whose grandson Harry died avoidably at East Kent and who was a large reason for this inquiry coming about. The report is clear and pulls no punches, as you would expect from Bill Kirkup. However, we are seeing the same themes as we saw at Shrewsbury and Telford and Morecambe Bay before that. Currently there is an investigation into grave problems at Nottingham’s maternity services, led by Donna Ockenden. 38% of maternity services in England are rated inadequate or requiring improvement, and the number of clinical negligence claims about maternity service has gone up by 20%.
The trail of lost or ruined lives is getting longer and longer, and yet in spite of report after report making damning conclusions and urgent recommendations, not enough is being done to improve safety. In my opinion, what urgently needs to happen is recruiting and retaining enough midwives and doctors, improving training, and changing the culture in maternity services. There is still a sense of tribalism between the professions, and a reluctance to always put safety first – even before mantras like ‘natural birth’.”
September 16, 2022
The Doctors Association UK and the patients’ charity Action against Medical Accidents have agreed the following joint statement and call for action to coincide with World Patient Safety Day
(17th September 2022).
Dr Jenny Vaughan (‘Learn Not Blame’ Lead for Doctors Association UK) and Peter Walsh (Chief Executive of Action against Medical Accidents) said:
“There are hundreds of thousands of incidents resulting in avoidable harm and deaths to patients in the NHS every year. Whilst there will always be some things that go wrong in such a vast, complex and risky activity as healthcare, this is far too many. There is no one ‘golden bullet’ solution, but we, as representatives of doctors and patients, are calling on the Government and the NHS to address two key issues as a matter of urgency.
1. Sufficient resources need to be allocated to the NHS. Too many NHS settings are understaffed and there are shortages of key personnel. Add poor morale into the mix and this is a disaster waiting to happen. No doctor (or other health professional) should be in a position where they have to work unreasonable hours or in such stressful, under-staffed and unsafe environments. It is not fair to doctors, and it is not fair to patients. It is also a false economy, as it leads to avoidable harm and deaths and all the human and financial collateral damage that follows.
2. A genuinely ‘Just Culture’ needs to be developed and supported across the whole health and social care system including the respective UK departments of health and social care and regulators. Such a culture needs to apply equally to all health professionals and to patients and their families.
We both support the principles of ‘Learn Not Blame’ published by the Doctors Association UK. Doctors (or other health professionals) should not be blamed or ‘hung out to dry’ for system failures. There needs to be full corporate responsibility allowing the circumstances which bring these failures about. Health staff should be supported through the trauma of having been involved in an incident that led to harm. Rarely, there should also be individual accountability when a health professional is intentionally reckless or unable to perform their duties safely. Consequences must be fair and proportionate.
We both support the principles of ‘What Just Culture should look like’ published by Action against Medical Accidents. The NHS has a moral duty of care to patients who have been harmed or their families. Provision must be made to provide different kinds of support for harmed patients or their families as described in the ‘Harmed Patient Care Pathway’. Patients/families have a right to know the truth and be assured that lessons will not only be learnt but acted upon. Legal redress is a recognised part of this process. It can be an important safety net when matters can not be resolved in less adversarial ways. Diminishing access to justice for people affected by healthcare harm or a doctor’s right to defend themselves from allegations they consider invalid is unacceptable in a ‘just culture’.
Just culture should apply from top to bottom of the health and social care system. This means national as well as local health and social care policy and practise having to be in accordance with just culture principles.
On behalf of both doctors and patients we call on UK governments and the NHS to address these issues as a matter of urgency.”
August 23, 2022
AvMA is pleased to announce the appointment of a new Chief Executive who will replace Peter Walsh, AvMA’s Chief Executive since 2003, who retires at the end of 2022.
Paul Whiteing joins AvMA on 5th December from the Financial Ombudsman Service where he has been a Lead Ombudsman and Director of casework since 2014. In this role he leads a number of teams responsible for resolving disputes between financial businesses and customers. Prior to that he has held a number of senior positions in both the not-for-profit and public sectors. Paul said of his appointment:
“I am delighted to be joining AvMA and continuing to build on the great and vital work of Peter and his team have delivered over many years to support people affected by avoidable harm in healthcare. I am passionate about this, and other forms of injustice, and look forward to building on AvMA’s excellent work.”
Peter Walsh remains the Chief Executive of AvMA until the end of 2022 and will have a handover period with Paul Whiteing in December before Paul takes on full responsibilities as AvMA’s Chief Executive on 1st January 2023.
July 14, 2022
AvMA reaction to appointment of England’s first Patient Safety Commissioner:
Action against Medical Accidents (AvMA – the charity for patient safety and Justice) welcomes the appointment of England’s first Patient Safety Commissioner announced by the Department of Health and Social Care today. AvMA gave evidence to the Cumberlege Inquiry which gave rise to the proposal of a Patient Safety Commissioner. However this appointment is only seen as a small step in the right direction.
AvMA chief executive, Peter Walsh said:
“We welcome the appointment of the first Patient Safety Commissioner in England. However, we are conscious that this commissioner’s role is limited to the area of medicines and devices, which is an important but relatively small part of patient safety work. The Government has missed an opportunity to appoint a Patient Safety Commissioner with a much wider role in promoting good patient safety culture and patient and family empowerment across healthcare. It remains a scandal that the Government refuses to fund specialist advice for people who the NHS has harmed through lapses in patient safety, and even has plans to reduce their access to justice. We look forward to working with Dr Henrietta Hughes with a view to addressing these and other pressing improvements in patient safety and responding to harmed patients and their families”