Bioethics, Health, Top Stories

Patient Safety and the Medical Omerta

September 17th, 2020 will mark the second anniversary of the World Health Organisation’s World Patient Safety Day, a sign of the progress made in highlighting the risks of iatrogenesis—harm caused by medical negligence or error. The loosely defined patient safety movement grew from the work of the American paediatric surgeon Lucian Leape, and the publication of the 1999 Institute of Medicine paper ‘To Err is Human,’ both of which succeeded in drawing attention to the risk of being inadvertently killed or otherwise mistreated by healthcare providers. The patient safety movement has subsequently called for better detection and investigation of error, and while official UK data estimates up to 12,000 deaths from medical error per year, the voice of the medical profession in these matters has been conspicuously quiet.

Inquiryitis

Here in the UK, there has been no shortage of healthcare scandals within the publicly funded National Health Service (NHS). The history of public inquiries into the NHS reminds us of the inherent power imbalance between healthcare providers and the public. However, over 130 such inquiries have been held since the NHS’s founding in 1948, so the announcement of yet another has long since ceased to be a notable event. The number of recommendations in these reports has so far ranged from 0 to 290, but an invariable feature is the refrain that learning from previous inquiries failed to take place. Following the bizarre occurrences at Ashworth Hospital in the 1990s, the Fallon Report coined the term “Inquiryitis” to describe the reflexive launching of inquiries following any major healthcare scandal.

Inquiries may be useful for establishing the facts of what occurred (although even this has been disputed),1 but what use does this serve if lessons are not learned? And whose job is it to enact the recommendations anyway? Sara Ryan of Oxford University writes that the cathartic release that public inquiries allegedly provide to affected families sidelines the pain and labour that bereaved families endure before, during, and after the investigative process.2 In Ryan’s case, the healthcare provider denied accountability for the death of her 18-year-old son Connor Sparrowhawk for almost five years; in her words, “Families should not have to fight for justice and accountability from the NHS.” But since this remains the case, it is unclear what the inquiries have achieved besides a demonstration of performative scrutiny.

The risks of self-regulation

There has certainly been some progress in levelling the playing field for the public’s dealings with doctors. A relative increase in democratic participation, increased suspicion of traditional institutions, and easier access to information have resulted in a medical profession that is more inclined to respect the rights and rational capabilities of patients than in previous centuries.

But the power of the medical profession is not just limited to the intimate interaction between doctor and patient. The training the profession receives, along with the specialised language and its associated rarefied meanings, allow for a patient’s treatment to be recorded in a manner that is almost unintelligible to anyone but other medical practitioners, and often further limited to those within the same specialty. A gynaecologist’s decisions, for example, are difficult to judge unless by another gynaecologist, or perhaps an experienced specialist nurse in gynaecology.

This allows for the development of a form of tribalism that protects against internal scrutiny and can allow entire departments, even entire medical specialties, to engage in practices that would be considered unethical to the outside world but, given how widespread they are, are then described as “cultural.” But not all unethical behaviour is embedded within, and therefore blameable upon, a culture. Sometimes inaction from the medical profession after patients are harmed is the result of a rational and self-interested decision.

The medical profession’s inaction

Even a cursory examination of public inquiries and high-profile medicolegal cases reveals how often doctors have been aware that harm was being inflicted on patients but took little or no action to expose it. Other staff, such as nurses, physiotherapists, and administrators may have been aware. Nevertheless, doctors are best placed to decipher the obfuscatory language used to smokescreen questionable practices, and along with their higher incomes, they enjoy a more privileged social standing and have a codified duty to speak up courtesy of the General Medical Council (GMC).

The profession’s track record on speaking up is poor, even so. The British serial killer Harold Shipman was generally respected by his medical colleagues until Sally Reynolds, a GP who had been working in the local area for just a few months, pursued an investigation into his murders. The anaesthetist Stephen Bolsin was singular in raising concerns about the high death rates within the Bristol paediatric cardiothoracic department and paid the price by being unable to find employment in the UK after those concerns were vindicated. The Mid-Staffordshire Inquiry Report exposed poor nursing and medical care that caused several hundred deaths—it makes for depressing reading, not least because so few medical staff raised the alarm. One such death was that of Gillian Astbury, a 66-year-old diabetic lady who died after a 10-day admission with hyperglycaemia due to insufficient insulin. A nurse lost her licence to practise due to a failure to check and administer Gillian’s glucose control. Yet, even though no medical notes were recorded on several days and there was no evidence that the fatal diagnosis was considered prior to her death, no doctor was held similarly accountable.

Although poor clinical care may indeed result from a normalisation of low standards due to poor leadership and chronic underfunding, this does not justify inaction when doctors become aware of a problem. Doctors report that a major barrier to speaking up is a fear of reprisal but this explanation is unsatisfactory given that concerns can be raised anonymously. A GMC survey of doctors in 2013 found that just five percent of respondents had unaddressed concerns about patient care in the past year. Of these, around a third had never reported their concerns before completing the survey.

Counterintuitively, as doctors became more experienced the chance of them having concerns about patient safety actually fell, with just 2.8 percent of the most experienced doctors in the survey having any concerns. It is also worth noting that 83.5 percent of respondents had no concerns at all about patient care in the past year, compared to the 77 percent of nurses who believed that patient care was compromised “several times a month or more” due to short staffing. Notwithstanding this dubious lack of awareness, a valuable 2018 survey by Archer and Colhoun revealed that even when consultants were aware of patient safety incidents, the majority of concerns were simply not reported.3

Who are the second victims?

When professor Sir Liam Donaldson, former NHS Chief Medical Officer and former WHO Envoy for Patient Safety delivered the Parliamentary and Health Service Ombudsman Annual Lecture in 2018, he remarked that, “The patient safety literature talks about the second victim. Our principle concern is, of course, for the patient that’s harmed, but there is also harm for the staff involved.” An entire academic literature exists describing the suffering of these “second victims”—there is even a taxpayer-funded website offering resources to support staff traumatised by the harm inflicted on the patient. Bereaved families, meanwhile, have to rely on Action against Medical Accidents, Inquest, and other such charities, and fundraising efforts to cover the costs of legal counsel.

On December 23rd, 2010, a previously healthy three-year-old boy named Sam Morrish died of sepsis. Despite years of denial from the hospital’s staff, it was eventually revealed that errors at every level of NHS care had been made and his death was entirely avoidable. The consultant paediatrician, a former medical director at the hospital, did not look at the notes before signing the death certificate and therefore claimed to be unaware of the major delay in antibiotic administration that contributed to Sam’s death. Although Sam had been under his care, he later chaired the “impartial” meeting to review the child’s clinical management. Unsurprisingly, the outcome of this and the hospital’s subsequent internal review was that the death was tragic but unavoidable. It was only after four years of persistence from the family that the litany of errors came to light.

Harry Richford’s birth and death just seven days later was so poorly managed that the events would be more typical of Third World healthcare. The hospital and its doctors denied error for as long as possible, and even claimed on the Child Death Notification Form that the death had been “expected.” It took two years for the hospital and its staff to accept responsibility, but only after an official inquest report was published—an inquest which had to be instigated by the family because the hospital’s staff refused to report the case to the coroner.

The experiences of Sam’s, Harry’s, and Connor’s families are unfortunately not rare. Common themes are easy to identify—years of denial, admission of errors but none that materially altered the outcome, highly incompetent and insensitive NHS staff, and a lack of emotional support for the families involved. The case of Bethany Bowen, a five-year-old girl who died from complications of an elective splenectomy, offers a valuable insight into how denial and minimisation of error has become so pervasive. In a memorandum submitted to the Parliamentary Health Select Committee in 2008, Bethany’s mother Clare Bowen wrote this:

The time has to come to acknowledge that medical staff may not always be forthcoming with all the facts following the death of a patient that they were directly involved with. To do so could damage or even terminate their career, and implicate colleagues with whom they work closely.

It should also be recognised that it is not in the interests of the NHS Trust to publish information that reveals human error and serious shortcomings in procedure. They have a reputation to protect.

This may seem obvious, but the experience of the witness both in the 16 months prior to the inquest and during the inquest itself, is that the testimony of the doctors is ultimately decisive in determining the facts.

This echoes Mulcahy’s important 2003 study of NHS complaints which found that “doctors seek to externalise blame, maintain the image of the competent expert-knowledge worker and feel justified in making assertions about the superiority of their form of narrative.”4 The tremendous patience and resilience required by grieving families to question healthcare providers is described by Scott Morrish, Sam’s father, in a statement given to the Public Administration Select Committee in 2015:

The absence of a “system for learning” can force patients into the often dysfunctional and ram-shackle world of complaints systems which in turn, can cause yet more harm. The need for a complaint in such circumstances is, in itself, symptomatic of problems. The burden of learning should not fall upon the shoulders of patients, or depend upon them for impetus, especially at times when most in need of support and least able to cope… Learning should take place irrespective of whether there is a complaint or not.

It is regrettable that, in the academic world, Sara Ryan is unusual in describing the suffering inflicted on families by healthcare providers’ denial and minimisation of concerns. An excellent 2019 BMJ article written by several American patient safety advocates calling for the end of the term “second victims” signals progress in shifting the focus from the perceived needs of healthcare staff towards greater justice for patients and their families.5 Considering the term populated the literature for almost two decades with little dissent from the Academy testifies to the difficulty of the task that patient safety advocates have taken on.

The limitations of the “human factors” literature

While doctors fail to speak up in the face of avoidable harm, the academic specialty of “human factors” provides a space into which discussion of medical error can be funnelled without paying attention to uncomfortable truths. Wachter and Gupta’s Understanding Patient Safety defines human factors as “concerned with the interplay between humans, machines, and their work environments,” providing almost limitless bounds to a conception of medical error which downplays doctors’ responsibilities. References in the human factors literature to the aviation industry’s blame-free reporting culture are common, but the key difference between the two industries is that while an entire airline’s crew has a stake in reporting safety incidents, healthcare staff suffer no ill-effects if harm to patients remains unreported.

The human factors literature construes healthcare workers as lacking in individual agency and only acting in response to some systemic malady, for which policies, protocols, training exercises, or managerial expertise are the prescribed treatment. The downstream orthodoxy is that most clinical errors occur as a result of systemic failings. But is this a tenable position when most clinical errors are never reported? Archer and Colhoun’s study respondents were mostly consultants, and the most common reason for not reporting patient safety incidents was a perceived lack of time. Could it be that incidents related to individual failings are in fact less likely to be reported to avoid criticising oneself or close colleagues?

Unexamined assumptions abound in the patient safety literature and successfully deflect attention from severe flaws in the medical profession that only honest reflection can correct. Soon-to-be-published data show that the rate of reporting of any harmful patient safety incidents by consultants averaged approximately six reports per 100 consultants per year. In light of these data, the idea that doctors are aware of concerns relating to patient care but are doing little or nothing to address them is unsurprising. There is no doubt that the NHS clinical governance systems are weak, but without at least minimal engagement from doctors improvements cannot be expected.

The moral responsibility to speak up

A community’s silence permits moral transgressions. Whether the context is policing or the Hollywood film industry, the public should not accept that unethical and even criminal activity will remain unreported to protect the career interests of those in the know. Even though the medical profession has an unequivocal responsibility to protect patients enshrined in its ethical code, a Freedom of Information request reveals that no doctor has ever been sanctioned for failing to speak up. The GMC would do well to take this responsibility more seriously—it has certainly sanctioned doctors for less important issues.

The sharp decline in popularity of the Catholic Church shows how difficult it is for public trust to be regained once power is abused—if the medical profession does not take its responsibility to protect patients more seriously it risks losing this trust. The paucity of criticism directed at the profession despite the catalogue of NHS care scandals is a source of wonder given the clear abdication of the responsibility to speak up. It is not possible to manufacture a healthcare system based on moral principles unless it is comprised of morally committed agents, and while the rhetoric of putting patients first is apt, the time for action to match it is overdue.

 

Habib Rahman is a specialist registrar in cardiology and general medicine based in London and south-east England.

References:

1 Walshe, K. (2019), Public Inquiry Methods, Processes and Outputs: an Epistemological Critique. The Political Quarterly, 90: 210-215. doi:10.1111/1467-923X.12691
2 Ryan, S. (2019), NHS Inquiries and Investigations; an Exemplar in Peculiarity and Assumption. The Political Quarterly, 90: 224-228. doi:10.1111/1467-923X.12703
3 Archer G and Colhoun A (2018). Incident reporting behaviours following the Francis report: A cross-sectional survey. Journal of Evaluation in Clinical Practice, 24(2). Pages 362-368.
4 Mulcahy L (2003) Disputing Doctors. Open University Press. Page 147.
5 Clarkson MD et al. (2019). Abandon the term “second victim” BMJ; 364 :l1233 doi: https://doi.org/10.1136/bmj.l1233

Comments

  1. Is there reall a person with that name? Only in America

  2. Have we finished with the cops already? By all means, lets go after the docs next.

    They’re a secretive tribe with “specialized” lingo! The horror!

  3. Yes, I agree. While I am by no means claiming doctors do no harm, or denying that better systems could be put in place to prevent malpractice, I do think a system of punishing doctors for not reporting will do more harm than good (namely, diminish the number of skilled doctors and thus increase the workload and the number of potential mistakes) It is quite possible that is not some code of silence that stops doctors from reporting, but being too damn busy. Again, I do think people overestimate the miracles modern medicine can perform. Also, I find it strange how on one level society preaches the “take me as I am” doctrine (i.e. “I’m not fat, I’m gorgeous. Deal with it.”) while demanding impossible levels of perfection from others, be it doctors, the police, teachers, or service providers (“Don’t make me Yelp!”)

  4. Prior to going after the docs we need to sock it to the fire departments for putting out the fires we start in the name of BLM, after all, it is clear that burning targets makes black lives better…sarcasm intended.

  5. When the problems outlined here occur in US healthcare, we are lectured that to eliminate them we need to implement a National Health Service.

  6. Medical malpractice is very common in both private and public systems. I’m not surprised to see how horrifying it is in a public system, however. The government being in charge and investigating malpractice creates a situation where the government is investigating itself.

    Accountability is necessary. Mistakes happen, sure, but keeping patients and their families in the dark is doubly traumatizing. its always better to speak about wrongdoing rather than letting it be “revealed.”

  7. That medical mistakes are a major cause of death is undisputed and I believe there is a problem in the medical profession in the UK with respect to the recording, analysis and monitoring of mistakes which severely impacts efforts to reduce their prevelance. However the approach of the article is to me entirely wrong, unsupported by evidence and counter productive.

    There is a call for ‘justice’ for patients and their families but what is meant by that? It implies punishment of an organisation or individuals. The reality is that mistakes will be made in any area of life what is important is that mistakes are minimised and the consequences of mistakes controlled through procedures, training, equipment etc. The demand for justice in an environment where everyone involved know or fear that they have made mistakes is a recipe to create a culture of silence and concealment.

    The idea that human factors is a means to obscure and downplay individuals responsibility is a grotesque distortion and at a stroke eliminates almost all means to reduce error. If a medical error occurs and the analysis of why it occurs excludes the processes and procedures used, the communication, the design of the equipment, the enviroment etc then all that is left is the fact that someone or some people made a mistake and we can sack them, train them or simply tell them to do better. Even then short comings in training which may indicate a systemic problem in capability management etc are exclude from analysis and therefore improvement. Worse most of teh means to improve teh situation are excluded from analysis, for example identifying that the introduction of a checklist, a standardised process that includes an independant review, improvement to the display of information, improvement in the environment or labelling and so on might help. Focussing on an individuals mistake makes analysis simple but excludes many of the available means to improve and does not reflect the reality that when serious incidents are investigated they usually result from the combination of multiple failures or weaknesses.

    If medical failures are willfull and reckless then certainly the concept of justcie applies but if they are the result of combinations of events and process contributed to by many then that has to be recognised if things are to be improved.

    The key is that institutions should be judged on their ability to document, monitor and control errors. An unusually low level of incidents and errors identified and addressed should be considered more serious than identifying serious short comings as long as those short comings are addressed.

  8. “Doctors differ and patients die.”
    Yet doctors agreeing probably kills more patients. Agreeing to cover-ups and silence and obfuscation. Consensus can kill.

  9. We’re seeing a broad, trending war on the productive. The competent. The bedrock of society.

    Are doctors capable of improvement? Probably. But why are we pressing those who are already doing the most for society (police, doctors) for improvement when there are so many who are literally net negative contributors to the world?

  10. Interesting , if short, article. I’m a Dr in the Australian system. Mandatory reporting of errors would be a shortcut to disaster. However, there is a hell of a lot that can still be done. I disagree with the author on this, and that systems and ancillary staff are somehow secondary in some if not many poor outcomes. There are all sorts of issues poorly dealt with. There are wilfully reckless/ negligent Drs (interesting that no one is asking to defund the healthcare system though eh?). Then there are chronically underperforming ones - boy are they hard to deal with." Hypothetically" how about a trainee that consistently underperforms, but when this is attempted to be dealt with they accuse the training college of racism ( even though there are plenty of specialists from his background already qualified?). “hypothetically” the training college then drops the issue like the hot potato it is & pushes him through… I’ve read some awful things about the NHS in the last few years about horrible coverups of patient death and damage. Amy Tueter on The Skeptical Ob outlines a few. Unfortunately wherever there are humans there are mistakes, mess, malice. The hope is slowly but surely we get better and better. On a personal note, PLEASE complain, in writing, if you are not happy with an outcome. Where there is smoke there is fire, and eventually an underperforming health practitioner will end up with an irrefutable mountain of evidence to sort them out. Eventually.

  11. I work in a hospital in the US, so I can’t speak to what happens in the UK or elsewhere, but I’m very familiar with the various “studies” that have been published over the years attributing huge numbers of deaths to medical errors.

    Most recently, in 2016 the British Medical Journal published a study claiming that medical errors were the third-leading cause of deaths in the US. The article was quickly given attention by CNN, WAPO, The Guardian, etc.

    The study also began to be picked apart almost immediately. Paraphrasing from the article below, to arrive at the number of deaths (250,000 per year), the authors relied on four studies, three of which were so small that they only had 14, 12 and 9 deaths. Other errors, such as inconsistency in defining “preventable” death, were also present.

    Following criticism for using flawed methodology, BMJ’s editor conceded that the methods used by the investigators were flawed, but stated that “the research community recognizes [this article] is for debate. The media may have picked it up and gone with it as a statement of fact, and the headline didn’t help with that.” This is deflection. Articles published in respected journals are in fact treated by the public and the media as gospel, as the editor is well aware.

    I’ve seen these studies come and go over the years. Few are helpful. Most use poorly defined criteria, such as one early study that claimed that if there was a medication error within 72 hours of a patient’s death the death was attributable to the error. (For example, a medication administered two hours later than the time it should have been given would count as an error.)

    The reality is that if patient deaths were actually caused by medical errors to the degree claimed in these kinds of articles, every hospital and every practitioner in the US would have been sued into the ground ages ago.

    Source: https://healthydebate.ca/2019/08/topic/medical-error-causing-death

  12. References in the human factors literature to the aviation industry’s blame-free reporting culture are common, but the key difference between the two industries is that while an entire airline’s crew has a stake in reporting safety incidents, healthcare staff suffer no ill-effects if harm to patients remains unreported.

    Acknowledging the validity of this concern still doesn’t make the blame-free culture entirely inapplicable to medical services.

    If there’s a system which is highly resistant to reporting & drawing appropriate technical conclusions due to fear of legal sanctioning & another ‘blame-free’ one where reporting does happen & useful technical conclusions are drawn @ the cost of attenuated legal sanctioning, then the latter is obviously preferable to the former. In plain words: if less kicking in the ass leads to more candid reporting & meaningful analysis/learning from mistakes then that’s preferable to having problems swept under the table & continuing with harmful mistakes.

    Obviously some level of personal responsibility is necessary, especially in case of repeated ‘offenders’. But again, if mistakes can be prevented due to a less-judgemental process, then that’s well worth the giving up a sanctions-happy approach: after all, what people care about is the avoidance of harm (up to and including avoidable/unnecessary deaths). It is a trade-off as everything in life is; & I believe that if less of a punitive approach leads to better practices, then that’s a trade-off well worth it.

  13. Yep, that’s the part of the article that left a bad taste in my mouth: the idea that justice does not exist unless it exacts vengeance, resulting in more broken and bloodied. I’m all for improving medical standards, but I fail to see how stressed out doctors will operate better if there is someone just waiting to damn them with an “accessory to murder” charge. Determining how someone was aware or should have been aware of someone else’s sins strikes me as a most precarious proposition. The inquiries would be extensive in terms of time, money and risk of unfair punishment. I also found it strange that the writer condemned physicians for using technical terms. I mean, by God, a diagnosis does need to be detailed and precise. Doctors will also most often describe a diagnosis to a patient in terms the patient can understand, but the doctor’s personal notes must be exact. Medicine is science. You can dumb down Newtonian laws to “what comes up must come down” but it is precise and highly technical math that put a man on the moon, not a catchy aphorism.

  14. US lawyers are much more active, which is part of the reason why treatments are more expensive here. We’re told that national health will reduce costs, which is odd since economics suggests that if something is free, more demand will ensue, but more supply won’t increase if everyone is paid less.

  15. I happen to be an engineer who is married to a doctor, and offer the following observation:

    Engineers are constantly second-guessing each other’s work. For a piece of equipment that peoples’ safety depends on, say a seatbelt or a footbridge, at least ten people with the competence and authority to fix mistakes will have reviewed the design. There are thousands of footbridges, and it’s so rare for one to fall down that when it does, it’s headline news.

    In contrast, when you’re sick, you will be treated by one doctor who most likely never discusses the case with anyone except maybe a specialist, and even then, the specialist will stay in his specialty and usually won’t get into whether the primary doc is doing the right thing unless he notices something egregious.

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