Two reports challenging failings in the current health safety management system

Welcome to our guest blog. This month’s blog is from Richard von Abendorff, one of a number of Patient Public Voices on NHS Improvement’s National Patient Safety Response Advisory Panel. Richard is expressing his personal view here, and we are very interested in knowing what others think on the subject.

If you would like to comment on this blog, please contact us here.

Two reports challenging failings in the current health safety management system

By Richard von Abendorff, Patient Safety Campaigner

September 2016

Comment piece on two recent publications:


These two important reports have wide implications beyond the specific cases and situations they address, significant as they are in themselves, as they show how slow the learning is and related failure by oversight bodies.

Firstly on the positive side. The amazing campaign by Sam Morrish’s family (with the support of the Patients’ Association) has, over six arduous and stressful years, forced numerous bodies to admit their failings and learn lessons. But these bodies should not have to be forced.

Even the Parliamentary and Health Service Ombudsman (PHSO), the final stage for complainants and whose report this is, has had to admit they themselves need to make significant change. In it questions are also asked of NHS England and its whole handling of the family, and not to my mind robustly followed through in their report

Also the safety alert , part of a developing alert system (ref 3), is a reminder that despite this vital intervention (nasogastric tubes) given to hundreds of thousands of people each year, things can go seriously wrong for a small but significant minority. 95 incidents were examined over a five-year period. This alert is about responses to this, one of many ‘never events’, which have to be investigated and reported to NHS Improvement’s Patients Safety team. It builds on previous alerts and focuses, like the Morrish Report, on the governance processes which need to be challenged at the very highest level to ensure that real learning and change occurs.

What is sobering and worrying about both these reports is how slow change is; the continued inability of too many investigations to identify core issues even for very serious incidents like these; and the lack of robust, sustained change.

Even when safety alerts are issued their recommendations are not embedded. Worse still, investigations too often do not refer to standards in these very alerts, if aware of their existence at all. This is a serious governance issue. Both AvMA (ref 3a) and Psychiatrist Minh Alexander (ref 3b) have done important research on compliance and responses to both safety alerts and coroners’ reports raising serious concerns about Trusts and the CQC. For example, Dr Alexander showed “The warning reports by coroners described elementary failures of serious incident processing and organisational learning”.

As has been said too many times, for undertrained and /or overworked staff to err is sadly inevitable, but for the organisations responsible for the system to fail to respond to these incidents adequately is unforgiveable.

Accountability for these failings, therefore, inevitably extends all the way up the system including NHS England’s handling of, and the PHSO’s whole approach to, working with patient families and safety incidents. My own current experience of the patient safety investigation and remedy system shows it is changing too slowly.

The root causes of failed investigations need to be better understood and addressed. The alerts guidance suggests much was learnt about strengths and weaknesses of the current never events investigation system. This insight and learning must be shared, to speed up improvement across the system. We cannot merely await outputs of the Healthcare Safety Investigation Branch in forthcoming years.

The PHSO report, in my opinion, evades the issue of root cause by saying no evidence of ‘cover up’ despite making multiple serious criticisms and revealing major administrative stalling processes. It then resorts to concluding it is simply that ‘alternative perspectives’ are not heeded! Why they are not heeded is the question. It is about reputation protection rather than honest challenging reflection and then changes to improve patients’ safety. Until trusts are transparent and even ‘proud’ to reveal failings and then deliver successful, robust, verifiable safety improving responses, nothing will change.

I am writing this for a number of reasons.

I want to emphasise the need for continued pressure on all NHS bodies to investigate and learn from harm events. In a previous article (ref 4) I encouraged patients and families to simply report these events (ref 5) using the National Reporting and Learning System (NRLS) even if they did not want to go through a formal complaints process . Although it should be noted for a harm event to have to await patients’ feedback to be reported and investigated indicates an earlier failure in the management system.

It must be noted the safety alert is focussed on commissioners and they must be held to account and demonstrate that patient’s safety is top of their agenda and seriously acted upon. Who holds them to account? What are consequences of not taking safety incident seriously?

The continued abysmal treatment of whistle-blowers is another indication of these systemic failing not being addressed. While there is talk of a need for a Just Culture model of response to harm events what about this context of systemic injustice for too many? (ref 6)

The NHS is under severe pressure, I believe also increasingly underfunded, while addressing serious welcome and to be celebrated challenges (more people living longer with multiple serious conditions) and we all have responsibility to ensure that it provides and develops safer care.

Suffering caused by poor interventions and by the poor response of bodies to failings must be addressed urgently, seriously and consistently. Patient Safety in NHS Improvement and, simultaneously, all other relevant bodies, as I argued towards the end of my paper ref 4, must be helped to be alerted to these issues and build on their important work.

To all of this I would add that all patient facing bodies could do more to help families do this and utilise the existing safety alerting system. AvMA already can and do help with this as well as helping people to feedback concerns about health providers to the Care Quality Commission (CQC).

Richard von Abendorff is one of a number of Patient Public Voices on NHS Improvement’s National Patient Safety Response Advisory Panel


2. and its fascinating and related resource guide






Disclaimer: Please note that the views and opinions expressed in this blog are those of the author and do not necessarily reflect the official policy or position of Action against Medical Accidents.