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GMC CEO: “If we act together, this report can be a catalyst for achieving a just culture in healthcare”

Reaction to the Independent Review of Gross Negligence Manslaughter and Culpable Homicide:

Niall Dickson, chief executive of the NHS Confederation, and former CEO of the GMC:

“There will always be a need for accountability by both organisations and professionals, but as this report recognises, we need to change the way we think about patient safety, from a conversation about blame to one of learning.

“This is already the ambition of national bodies concerned with safety, but in a climate of constrained resources and huge pressure on staff, it has proved incredibly difficult to gain the confidence of those working on the clinical front line that they will not be victims of a blame game.

“We know staff fear that if they engage in reflective practice, they open themselves up to liability or criminal proceedings, and this can limit what they are willing to share, in turn preventing meaningful learning from taking place.

“The report rightly identifies a need to introduce legislation to protect reflective practice. This will be a necessary step towards restoring faith in the system, but will require careful nuance to ensure that those acts of negligence that are found to be malicious are not afforded blanket protection, and that patients are protected from the very small number of incompetent practitioners.

“Renewed staff confidence will depend upon the way we develop a learning culture which will require  everyone involved to come together and act on the findings of this report.”

Dr Chaand Nagpaul, BMA council chair:

“When an error is made in a medical environment that is so serious that a patient loses their life, though incredibly rare, it is a tragedy, causing unspeakable distress to the person’s family and loved ones, as well as to the health professionals involved.

“We therefore welcome this review, which takes on board many of the points the BMA raised in its own submission2 – not least on the need for a just culture based on learning rather than blame – and builds on the important work from Professor Sir Norman Williams last year.

“This culture shift is vital to help avert such tragedies, and give the public confidence in the health service, while reassuring doctors and other staff that they will not be unfairly blamed when things went wrong.

“We welcome the recommendation that all healthcare providers should be consistent when conducting local investigations and in line with the relevant national frameworks. This, in our opinion, would alleviate issues of too much variation in who carries out investigations into serious clinical incidents. While that variability is of some concern, our greater worry lies in the lack of training provided to those involved. The BMA firmly believes that standardising local processes could lead to fewer cases being escalated to the criminal justice system.

“We also welcome the recommendation that, in England and Wales, any gross negligence manslaughter cases in healthcare are referred on only after consultation with the Chief Coroner. This should ensure that only the cases that warrant further investigation are referred to the police, and is also vital as some medically qualified coroners may have a different threshold from a legally qualified coroner and there may be unintended bias.

“However, when cases do become subject to criminal proceedings, it is important for investigators to seek good quality and objective expert medical opinion, something we are glad this report recognises.

“As the trade union and professional body representing doctors from across the UK, the BMA also knows too well the damage that recent high-profile cases have done to the profession’s confidence in the GMC. There is an urgent need for the regulator to repair its relationship with doctors so that they feel better supported to deliver a high standard of care for their patients.

“Specifically, we are glad that this review has backed both Professor Sir Norman Williams’ and the BMA’s position that the GMC should lose its right to appeal fitness-to-practise decisions made by its own tribunal service, and we similarly urge the Government now to introduce the legislative changes to allow this to happen as soon as possible. We also fully support the review’s call for doctors recorded reflections to be legally privileged.

“It is also imperative to recognise, as this report does, that mistakes rarely happen in isolation from wider system pressures, and these must be considered as part of any investigation. It is simply not fair that one person should carry the blame for a mistake, no matter how grave, that is the product of a series of failings across the workplace. This review’s recommendation for the appropriate authority to scrutinise the environments that doctors find themselves working in is a positive one, and this area’s particular focus on trainees, who often work under difficult conditions without appropriate support, is important.

“The BMA has repeatedly called for systemic pressures to be explored and recognised when errors occur, and has worked closely with other stakeholders, including the royal colleges, to help ensure workplace concerns can be raised quickly and safely. Through the work of the BMA – including that of our junior doctors committee and medico-legal committee – we hope that we can avoid seeing cases where medical error is inappropriately criminalised.

“Meanwhile, doctors from overseas backgrounds bring incredible knowledge and a wealth of insights through experiences in their home nations, which, as described in this report, often remains untapped due to lack of support and pastoral care when they arrive to practise in the UK. The BMA is happy build on the resources we have already developed for international medical graduates and those that employ and develop them, and to work alongside the GMC’s commitments to supporting overseas doctors to work and thrive in UK practice.

“That doctors from black and ethnic minority communities are more vulnerable to complaints and investigation, and are disproportionately represented in fitness-to-practise proceedings, is another concern that the BMA has long been raising, and we welcome this review’s work and recommendations in this area. A call for all healthcare systems to ensure an inclusive culture within workplace, education and training environments, is core to the BMA’s values and its vision for the NHS.

“While it is essential that the GMC and other stakeholders have committed to addressing issues in workplace cultures in the NHS, this must be tied to action to tackle other issues, such as improving training on equality and inclusion, embedding human factors in everyday practice, displaying compassionate leadership throughout health organisations and structures, and alleviating system pressures.

“Of course, this review is just a starting point, and we would urge the Government, the GMC, healthcare providers and other relevant bodies to urgently monitor, evaluate and regularly report on the implementation of the recommendations, and the BMA looks forward to working alongside these stakeholders to ensure the best for both doctors and the patients they go above and beyond to provide care to every day.”

Professor Russell Viner, President of the Royal College of Paediatrics and Child Health (RCPCH):

“When a child dies, the impact on the family is unimaginable. The trauma also deeply affects those healthcare professionals who have looked after that child. The recommendations in this review, if enacted, have the potential to reduce the number of preventable deaths by shifting the culture within the NHS away from blame and towards learning from errors.

“Mistakes are sadly inevitable but the consequences of those mistakes need not be so catastrophic if the right systems are in place to mitigate them.

“The case of Hadiza Bawa-Garba has had a profound effect on paediatricians and the wider medical professional. The accounts of systemic errors, short-staffing, IT issues and lack of support for this particular trainee that contributed to the tragic death of a child has led trainees to tell us they carry a sense of trepidation before the start every shift.  Many have experienced ‘that shift’ that could easily have ended in disaster.

“It is heartening that the review stresses that the public recognise the pressure on healthcare professionals who are working in an overstretched system and also that serious harm to patients is very rarely the result of an error made by one individual. We support the recommendation that, when there is significant criminal investigation into an individual, the systems around them must also be investigated. This is not about shifting blame or accountability, but recognising that individuals operate within a wider environment and should not become scapegoats – and failings of the system at large need to be addressed.

“The report states, and the GMC has accepted, that its handling of the Bawa-Garba case has damaged its relationship with the medical profession. This was undoubtedly the sense from many of our members. We therefore wholeheartedly support the recommendation that the GMC should not be able to appeal decisions by the Medical Practitioners Tribunal Service – and we call on government to make the necessary legislative changes promptly to ensure this is the case. As we said during the Bawa-Garba case, the GMC must be clear with the public and the medical profession about its role in investigations, if trust is to be rebuilt.

“The RCPCH also supports the recommendation that police investigating cases should have access to independent medical advice to help with decisions on whether to take investigations further.  Individuals involved in criminal proceedings must have proper support in place and it should be made clear what is expected of them. Coupled with this, there must be transparency both for clinicians and the public as to how decisions are made.  If this doesn’t happen, there is a grave risk that future clinicians will be put off entering the profession, further exacerbating existing workforce pressures.

“The emphasis of the report on reflection is absolutely right; only through reflecting on errors can clinicians learn from mistakes and outcomes for patients improve. The threat of criminal investigation does not result in fewer errors and only through building a culture of trust and reflection can progress be made.

“The RCPCH supports the recommendations in this review and our concerns have clearly been listened to. We stand ready to work with the GMC and other agencies to ensure they are implemented, and to support our doctors during investigations. We are also committed to helping ensure that every paediatrician returning to work after a period of absence has the necessary support in place to reduce the likelihood of errors occurring.

“This is a welcome report – but the burning question now for those who own the actions is how quickly will they be delivered? With other Medical Royal Colleges, we will move urgently to do our part.”

Professor Derek Bell OBE, President of the Royal College of Physicians of Edinburgh:

“The GMC’s case against Dr Hadiza Bawa-Garba undoubtedly affected their relationship with doctors across the country, so we welcome Leslie Hamilton’s recommendation that the GMC must rebuild trust with the profession. We think that this is essential, and the GMC appear to accept that relationships need to be rebuilt, which is a good start.

“Sadly, errors in care can and do occur, as we saw in the tragic case of Jack Adcock. In order to address this, all healthcare professionals must learn from serious failings in care.

“We also think that serious thought about reflective practice is required – an area where the GMC has regrettably lost the trust of doctors. We note Leslie Hamilton’s recommendation that the UK Parliament and devolved administrations could consider how legal protection could be given to doctor’s reflections. In any event, doctors’ trust and faith in the system must be re-established. Steps must be taken to ensure that reflection is used as learning tool, not as a means to attribute blame.

“The GMC, the NHS, the Medical Royal Colleges, professional unions and policy makers must encourage an open and no-blame culture, where the focus is on identifying and addressing system failures and risks, and where all staff and patients are empowered to raise concerns over standards of care. Only by doing so can we ensure that we learn from cases such as that of Jack Adcock, and prevent similar tragedies from occurring.

“Both during and after the GMC’s case against Dr Bawa-Garba, we have worked closely with our Trainees and Members Committee, to ensure that our Members and Fellows are provided with the most up to date information about key issues for doctors, including reflective practice guidance. In light of the Leslie Hamilton’s report, we will continue to do this, and we will also work closely with the UK Academy of Medical Royal Colleges, to assist in providing relevant professional training, development and support for doctors of all grades.”

Professor Jackie Taylor, the President of the Royal College of Physicians and Surgeons of Glasgow:

“Our whole profession was shocked by this case, which resulted in the tragic death of Jack Adcock and the subsequent prosecution of Dr Hadiza Bawa-Garba. Now we must learn lessons from this incident to ensure that we protect the best interests of patients and staff within the NHS.

“I’m glad that this report recognises that the actions of the GMC in this case undermined the trust that the medical profession has in our regulator. It will not be an easy task to rebuild this damaged relationship, but it’s vital that action is taken to build on the positive progress that has begun over the past year.

“Doctors must have confidence that the system is not loaded against them when mistakes are made. Developing a truly just ethos within the NHS means that we must all work together to create a learning environment, not a blame culture.

“We agree with the report that the GMC’s processes have been shown to be inadequate, and so we welcome the calls to update the legislation which underpins this. This must be brought forward by government as a matter of urgency. We also welcome the recommendation that action is required to ensure that reflective practice should be given legal protection. This would ensure the full transparency that is required to aid learning and improve the care that we all provide to our patients.

“It remains the case that the criminal threshold for the charge of gross negligence manslaughter in England and Wales remains lower than the equivalent charge of culpable homicide in Scotland. We believe that this report shows that the system in England and Wales can learn from the Scottish experience in developing a legal framework which encourages transparency and commands greater respect from victims, their families, and healthcare workers alike in ensuring that a just culture exists within our health service.

“Lessons must be learned from this case. The time for action is now.”

Charlie Massey, Chief Executive of the General Medical Council:

“We commissioned this independent review following the tragic death of Jack Adcock and the prosecution and conviction of Dr Hadiza Bawa-Garba for gross negligence manslaughter. The series of subsequent proceedings that followed have undoubtedly affected our relationship with the doctors we regulate.

“The report says we must rebuild trust with the profession, and we fully accept this challenge. Having reflected as an organisation, we are committed to acting on that and taking forward all the recommendations in this report directed to us.

“We share this report’s desire for a just culture in healthcare, and acknowledge that we have a crucial role in making that happen. We are already making progress. Work is underway to address some of the key issues raised in this report but there is plenty more for us to do.

“One thing this report and its recommendations make clear is that a just culture requires a lot more than the actions of a single regulator.

“The independent chair Leslie Hamilton and his working group have met with many stakeholders, including representatives of patients as well as doctors, right across the country.

“Importantly, as this was a UK-wide review, they made a point of examining what happens in Scotland, which has its own systems and law.

“Regardless of any geographic and legal differences, there needs to be greater consistency in the response to an unexpected death. Support for, and involvement of, patients’ families must be a priority before, during and even after an investigation into an unexpected death. Doctors need to feel they are part of a just culture when things go wrong.

“The report highlights the new evidence that the public are acutely aware of the pressures facing UK heath systems, and that this can affect their confidence in the care doctors are able to provide.

“This reinforces why we must all do what we can to make sure doctors are training and working in safe environments, for the benefit of patients, and why the GMC must work with the system to effect change.

“The report also recognises that GMC processes are constrained by outdated and inflexible legislation, and calls on the UK government to reform the Medical Act to give us more discretion over which cases require investigation. We welcome this recommendation, and echo that call.

“The recommendations in this report will help us move towards the just culture that we all want and that will benefit healthcare.

“We fully accept the recommendations that are for the GMC, and I urge those other organisations named to carefully consider the recommendations that are for them, as they too may need to make changes.

“If we all act together, this report can be a catalyst for a step change in achieving a just culture in healthcare, and with it the fundamental improvements to the care that patients and their families expect and deserve, and that doctors strive to deliver.”

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