Hunt Pledges New Support for Doctors to Learn From Mistakes

Peter Russell

June 11, 2018

Doctors and nurses will be supported to examine and learn from ordinary mistakes without it being used against them, health secretary Jeremy Hunt has insisted.

New measures to improve patient safety and protect health professionals from fear that they could be compromised by their own reflective practice documents have been announced by the Department of Health and Social Care.

Review Into Gross Negligence Manslaughter

It followed a rapid government review into gross negligence manslaughter in healthcare led by Sir Norman Williams, former president of the Royal College of Surgeons.

Following its publication, the General Medical Council (GMC) and the British Medical Association (BMA) said they were disappointed that doctors' reflective written notes would not be granted legal privilege to prevent them being used in gross negligence manslaughter cases.

However, the Williams report recommended that healthcare professionals' personal case notes should not be available to regulators investigating fitness to practice.

Among other measures announced by Mr Hunt today:

  • The rollout of a scheme in which every patient death will be scrutinised by medical examiners or coroners

  • The withdrawal of the right of the GMC to appeal Medical Practitioners' Tribunal rulings

  • A new programme offering doctors confidential data on their results and how they compare nationally to support learning and improvement

Mr Hunt said: "When something goes tragically wrong in healthcare, the best apology to grieving families is to guarantee that no-one will experience that same heartache again.

The Bawa-Garba Case

"I was deeply concerned about the unintended chilling effect on clinicians' ability to learn from mistakes following recent court rulings, and the actions from this authoritative review will help us promise them that the NHS will support them to learn rather than seek to blame."

The review came after concerns were raised by the medical profession about Dr Hadiza Bawa-Garba, who was struck off after the death of 6 year old Jack Adcock from Leicester, who died of sepsis in 2011.

Preventing the GMC from appealing fitness to practise decisions by the Medical Practitioner Tribunal Service was recommended by the Williams review. In a letter to Mr Hunt, Sir Norman said: "Such action will hopefully mitigate the distrust felt by doctors about their professional regulator, while maintaining effective public protection through the Professional Standards Authority's right of appeal."

A Missed Opportunity?

The move has drawn criticism from the GMC, which said it would significantly reduce its ability to protect patients. Prof Sir Terence Stephenson, GMC chair, said: "Our appeals have been upheld in 16 out of 18 cases heard by the courts. We believe our actions have provided greater public safety and maintained public confidence in the profession through these rulings, all but one of which involved sexual misconduct or dishonesty."

The GMC described the decision not to grant legal protection in the criminal courts to doctors' reflections as a "missed opportunity to promote a genuine learning culture".

The BMA said it still supported full legal protection. Dr Chaand Nagpaul, BMA council chair, said: "Doctors must feel able to report errors and reflect on their own mistakes openly, without the fear of these reflections being used against them at a later stage."

However, the Williams review concluded: "No other sectors or professions have equivalent privilege, and to provide an exemption for reflective practice material would rightly cause concern that healthcare professionals are above the law."

Mr Hunt has also announced that GPs and ambulance trusts "will be the next focus for reviewing deaths to help understand and tackle patient safety issues".


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