Zero E-Book

Jeremy Hunt

• Herausgeber: Swift Press
• Kategorie: Geisteswissenschaft
• Sprache: Englisch

Seitenzahl: 377

Veröffentlichungsjahr: 2022

Beschreibung

'A thoughtful, serious and well-written book that tackles an immensely important subject' - Observer How many avoidable deaths are there in the NHS every week? 150. What figure should we aim for? Zero. The NHS is the pride of Britain. It's an army of highly skilled and talented healthcare professionals, armed with the most cutting-edge therapies and medicines, and a budget bigger than the GDP of most countries in the world. Yet avoidable failures are common. And the result is tragic deaths up and down the country every day. Jeremy Hunt, the longest-serving Health Secretary in history, knows exactly what the cost is. In the letters he received from bereaved family members, he was constantly confronted by the heart-breaking reality of slip-ups and mistakes. There is increasing conflict between public pride in the NHS and the exhausted daily reality for many doctors and nurses, now experiencing burnout in record numbers. Waiting lists are up, staffing numbers inadequate, and all the while an ageing population and medical advances increase both demand and expectations. With pressures like these, is it surprising that mistakes start to creep in? This great British institution is crying out for renewal. In Zero, taking the broadest approach, thinking through everything from staffing to technology, budgets to culture, Hunt presents a manifesto for that renewal. Mistakes happen. But nobody deserves to become a statistic in an NHS hospital. That's why we need to aim for zero.

Leseprobe

This book is dedicated to the doctors, nurses and managers around the world who have been troubled for too long by the high levels of avoidable harm and death in modern healthcare. It is dedicated to the bereaved families who have taken up the cause on behalf of a lost loved one, not for financial gain but simply to try to prevent the same tragedies being repeated. And it is dedicated to the NHS, whose founding values are based on the principle that every single patient matters.

All royalties from this book will be donated to Patient Safety Watch, which funds research by Imperial College London into preventable harm and death.

Contents

IntroductionPart One: The Three Big Causes of Avoidable Harm1 Blame2 Short-Staffing3 MoneyPart Two: Culture Challenges4 Targets5 Hierarchies6 Litigation7 GroupthinkPart Three: Solutions8 Transparency9 Continuity10 Homecare11 Prevention12 TechnologyPart Four: Making It Happen13 Communication14 Zero15 Patient PowerPostscriptNotes

Introduction

Could this be a 1948 moment?

1948 was the year a Labour government, with cross-party support, set up the National Health Service. Health Minister Aneurin Bevan famously dealt with opposition from the doctors’ union, the BMA, by ‘stuff[ing] their mouths with gold’.1 He had opposition from Conservatives in parliament who, while supporting the principle, wanted GPs to be employees of the new service but keep hospitals independent (Bevan’s plan did the opposite). To his credit, he was willing to smash whatever china necessary to get the NHS off the ground – and in the process created what has become our most treasured national institution, described in poll after poll as the single biggest reason people are proud to be British.2

The NHS has stood the test of time because the values it stands for have become entwined with what it means to be British. We are proud that whoever and wherever you are – rich or poor, young or old, north or south – you can always get the healthcare you need, irrespective of the size of your bank balance. We were not actually the first country to set up a universal healthcare system (that honour goes to New Zealand3), but we are the probably the best known. By setting up the NHS at a pivotal moment for the world, right after the Second World War, we helped make universal provision part of the definition of a civilised country. Forty-three countries now offer a comprehensive version of it, including most developed countries, except of course America. Most others are planning universal provision. The NHS has had a huge influence beyond its shores.

But today, that pride in the NHS is starkly at odds with the exhausting daily reality for doctors and nurses. As the service starts its slow, blinking recovery from the Covid-19 pandemic, many feel a sense of helplessness. Frontline professionals are experiencing ‘burnout’ in record numbers.4 Patients are wearily coming to terms with huge backlogs that have built up for cancer care or elective surgery. The institution is crying out for renewal, not just because of the threat of new viruses but because of the changing nature of illness caused by an ageing population.

In this book, I argue that the foundation of any reforms must be to improve the quality as well as the quantity of care delivered. NHS care, for all the pride we feel in it, is not always the best. In most studies, the NHS is around the middle of the pack for the quality of care it offers, tending to do better on the accessibility of care than outcomes.5 But why shouldn’t NHS care be of the highest quality too?

Right now, that seems a tall order. Enormous backlogs in treatment have built up during the pandemic. If they are not managed properly, there will be pressure to compromise on standards of safety, which will reduce, rather than increase, the quality of NHS care. Some go further and say the NHS can never be the highest quality, for financial reasons: a taxpayer-funded system will never be able to afford the billions needed to pay for advances in modern medicine. Others think there is an inevitable trade-off between access and quality: ‘free’ systems will never be able to match the standards of care in private ones, because they lack the incentive to put customers first.

Having been Health Secretary for longer than anyone else – with all the ups and downs that involved – I profoundly disagree. The pandemic showed the brilliance of British science and the dedication of the NHS workforce, so two key foundations are in place. Funding matters, although, as I will discuss later, the relationship between quality and money is more complicated than first meets the eye. But to offer the very best care we need to address a major structural problem, one that is faced not just by the NHS but by countries everywhere: finding a way to deal more honestly and humanely with the shockingly high levels of avoidable harm and death in modern healthcare systems.

Most tragedies are treated as ‘inevitable’, when in fact they could be prevented simply and cheaply. According to the WHO there are 2.6 million avoidable deaths every year in healthcare systems, making it a global top ten killer, affecting more people than tuberculosis or malaria, and nearly as many as HIV and road traffic accidents.6 We need to become better at learning from mistakes.

Other industries have succeeded in tackling avoidable harm and death through a root-and-branch change in culture. As Health Secretary, I initially shied away from ‘culture change’ as being too nebulous and unlikely to have any practical impact. Ultimately, however, I concluded it was the most important change of all, without which improvements only have limited impact at best. Change is hard to deliver, but surely our forebears were no less weary – or broke – recovering from the Second World War in 1948? Focusing on delivering the safest, highest quality care in a way that eliminates avoidable harm and tragedy is the way to set the NHS up for the rest of the century – our very own 1948 moment.

This book is not about me, but I should briefly explain how my interest in eliminating harm in modern healthcare systems arose. My journey started on Monday, 3 September 2012.

It was a glorious late summer day. As the government minister responsible for putting on the London 2012 Olympic Games, I was at the gleaming new Stratford stadium for the Paralympics. Despite the excitement of the sport, I was rather preoccupied. The Prime Minister, David Cameron, had come back from his holiday and was starting a process that always terrifies even hardened ministers: a Cabinet reshuffle.

I had no idea what was in store for me. Lots of pundits thought I would be sacked. Although I had just helped deliver a successful Olympics, I had been embroiled in the Leveson Inquiry into Rupert Murdoch’s BSkyB bid. My special adviser had been forced to quit, and for days I had woken up with journalists waiting outside my front door wanting the ‘money shot’ of me leaving home on the day I resigned. Although the Leveson Inquiry eventually vindicated me,7 there were many wild accusations flying around – the Guardian even printed a huge, grainy picture of me on their front page with the headline ‘Minister for Murdoch’.8 As I sat in the Olympic Stadium, amidst the cheers and excitement of the athletics, I felt anxious awaiting the Prime Minister’s call. I knew I was vulnerable.

The next morning the summons to No. 10 came. As I walked through the famous black door, I experienced the well-oiled choreography of British government reshuffles. Ministers are met as soon as they’ve crossed the threshold into No. 10 and discreetly shown to a waiting room – always avoiding other Cabinet ministers on their way in or out. I was shown to the White Room, a beautiful room on the first floor used for bilateral meetings with visiting heads of government. Then there was a knock on the door, and I was ushered down to the Cabinet Room. On one side of the long, oval-shaped table sat just two people: the Prime Minister and his trusted chief of staff Ed Llewellyn. I sat directly opposite them nervously.

Then I got the shock of my life. Cameron asked me to be Health Secretary. For someone who had been under the cosh, it was a huge promotion.

He was in transmit mode, so didn’t pause for breath as he started outlining what he wanted me to do with the job. ‘We need someone in this job who speaks English’ was one of the phrases he used alluding to the difficulties the government had experienced in communicating Andrew Lansley’s reforms. Then he suddenly stopped in mid flow and said, ‘First, I should check – will you accept the job?’

‘You bet,’ I said, ‘even though I am pretty daunted.’ Quite the understatement.

After all, this wasn’t just any department. This was the department that oversaw our most treasured institution and the fifth biggest employer in the world.9 Uniquely, 80% of health funding in the UK comes through central taxation,10 so pretty much everything that goes wrong is laid at the door of politicians. Budget increases would be difficult amid tight national finances. However much money you gave, for many it would never be enough. And any attempt to change our precious institution would spark fierce opposition, as Lansley’s 2012 reforms had shown.

But my trepidation at taking up a potentially poisoned chalice was overshadowed by the sense of awe: to be working in a job where your decisions don’t just have a long-term impact but make an immediate and life-changing difference to people’s lives is unusual in politics. It was a huge responsibility.

As I left Downing Street, I told the media that being responsible for the NHS was the biggest privilege of my life.11 It was a hurried, made-for-camera comment. But if it was manufactured initially, I soon came to believe it from the bottom of my heart. I had just agreed to something that would change not just my political career but the direction and purpose of my life.

When I accepted the job, I was an outsider to the world of health. But dealing with inexperienced ministers is something civil servants are quite used to, indeed trained for. When I walked to my new office in Richmond House, on the other side of Whitehall from the Downing Street gates, I was met by extremely welcoming officials. They were somewhat battered after the battles they had been fighting over the Health and Social Care Act, but could not have been kinder or more supportive as I got to grips with the immense task at hand.

Unfortunately, I also went on to discover practices in modern medicine that shocked me to the core.

I came to realise this largely by speaking with patients, something I ended up doing in a very direct way because of something that happened at a rather curious moment: Margaret Thatcher’s funeral.

Held in St Paul’s Cathedral, it was of course no ordinary funeral. As a member of the Cabinet I was sitting in a row behind Gordon Brown, Tony Blair and John Major. I remember singing ‘I Vow to Thee My Country’ and thinking it must rank as one of the most British moments of my life.

The eulogy was delivered by Richard Chartres, the Bishop of London and a long-standing friend of Margaret Thatcher’s. He read out a letter she had received from a nine-year-old boy called David, to which she had replied personally. I sat there, and thought: In my seven months as Health Secretary I haven’t read a single letter from an NHS patient. If Margaret Thatcher had found the time to do personal replies as Prime Minister, couldn’t I?

Not, of course, that I didn’t receive correspondence. The Department of Health received more letters than any other government department. There was an army of fifty officials in the correspondence unit, whose job was to draft replies and to a certain extent protect ministers from the highly personal and emotional missives received from people who had experienced problems with their care. But it felt wrong that I was not actually seeing any letters myself. Good chief executives stay closely in touch with what their customers are saying – and although the NHS is not a business the principle is the same. So when I went back to my office I asked my civil servants to pass on to me one letter every day for a personal reply. I wanted to send a handwritten letter, not just ‘top and tail’ a letter drafted by officials.

I didn’t know it at the time, but this request sent the department into a spin. Sir Humphrey-like meetings were held behind my back to work out if they could dissuade me from such a thoroughly dangerous idea. They saw their job as shielding me from such letters, not exposing me to them. Furthermore, it was the job of hospitals and not the department to deal with ‘local complaints’. No letters came forth.

So I chased the department. And about a month later the first letter arrived.

‘I am just writing to thank you for the fantastic NHS care I received…’

‘No,’ I said. The point was not to tell me what was going right, but to show me what was going wrong.

Eventually, I did start getting some proper complaint letters. They were eye-opening and sometimes horrifying. It didn’t matter what form they came in – sometimes an email, sometimes shaky handwriting from an older person, sometimes on scraps of notepaper with terrible spelling – the cry for help was clear. Stories about young children lodged particularly in my mind, as a father of three. One of the earlier letters hit me especially hard: it was from a man in Cumbria, writing about his teenage daughter who had killed herself the day after an appointment with a mental health nurse.

In the very first letter I replied to, I apologised for the terrible care someone had received. The next day my letter came back with a note from officials saying, ‘Apologies not permitted.’ Presumably someone was worried about a legal admission of liability. However, I knew that the law is perfectly sensible in this respect and apologies do not count as an admission of guilt. The letter went out unchanged.

I then got into a daily routine of replying to one such letter every morning. I always asked for the day’s letter to be sitting on my desk waiting for me when I arrived for work, with time put aside in the diary to allow me to do a handwritten reply. As it was the first thing I did every day, those letters shaped my day. They also persuaded me of something: I needed to focus my attention on preventable harm and death. Many of the stories in this book come from those letters, although where requested I have changed names to protect anonymity.

Mistakes happen. In most fields the consequences are limited. In healthcare they can be fatal.

Nothing I say about the mistakes I recount in the pages that follow is a reflection on the competence or dedication of NHS professionals. During nearly six years in office, my encounters with the care they provided were always humbling. I remember meeting a nurse who had tracked down the long-lost relatives of a dying man and arranged for him to fly to Ireland to see them for the first time in twenty years; I met a heart surgeon who stopped a human heart in front of my eyes and then restarted it half an hour later when the surgery was complete; I was transfixed by a care home manager whose passion was putting a smile on the faces of residents unable to talk because of late stage dementia; I visited a GP who insisted on washing the body of a dead patient before the undertakers took it away; and I met countless cheerful, hard-working healthcare assistants who taught me to wash beds between patients and grinned when it was my turn to empty a commode.

The problem does not lie with individuals, but with healthcare systems around the world that generally ‘go after’ someone when something goes wrong, making it impossible for professionals to be open about mistakes. The result is a blame game that stops learning and allows the same mistake to be repeated, often countless times. Ending that culture – and the harm and tragedy associated with it – became my focus. It is why I have written this book.

I saw that flawed culture on a huge scale in the aftermath of the Mid Staffs hospital scandal, a terrible failure of care that led to between 400 and 1,200 unnecessary and often cruel deaths over four years between 2005 and 2009.12 My predecessor had set up a public inquiry led by Sir Robert Francis, which was due to report early in 2013. Because we knew the report wouldn’t pull any punches, the issue hung like a shadow over the Department of Health in my first few months.

‘You have to understand that in healthcare we harm ten per cent of patients,’ I was told wearily by Sir David Nicholson, who was the chief executive of the NHS from 2006 to 2014. By his own admission, David had made mistakes over Mid Staffs, but I developed enormous respect for him. We had little in common politically, but he was the most effective manager I ever met. By ‘harm’ he meant damage done to patients because of medical errors – in other words, something that could be avoided.

‘If ten per cent of patients are harmed, how many actually die as a result?’ I asked.

We have more data on this kind of thing than anywhere else in the world, so a remarkably precise answer came back. According to a study led by Helen Hogan and Nick Black, two eminent academics at the London School of Hygiene and Tropical Medicine, around 4% of hospital deaths had a 50% or more chance of being avoidable.13 When you do the maths, that turns out to be a rather dry way of saying that there are 150 avoidable deaths every single week. Many of these would have been frail elderly patients with a relatively short time left, but none the less, a huge number of lives were being cut short.

If English rates were typical across the world – and the NHS appears to be about the middle of the pack by international standards – that means millions of deaths a year globally, as indeed the WHO now recognises. But the crucial difference between deaths from medical error and deaths from, say, cancer is that every single one of them is immediately preventable. We are not waiting for a miracle cure. They could be stopped right now if best practice was followed.

If my daily letters were the building blocks for a mission, Mid Staffs became the catalyst that galvanised it.

My first instinct was to focus on transparency. All these avoidable deaths felt like a major scandal – but one that no one seemed to know about.

There seemed to be a kind of omertà around avoidable deaths in the NHS. This was partly because people at the top of the service thought their political masters would not want the bad publicity. But it was probably more from an understandable worry that talking about such deaths would damage public confidence in the NHS. Unfortunately, the corrosive consequence of such thinking was all kinds of terrible cover-ups in which both the Department of Health and the NHS were sadly complicit. When problems like Mid Staffs were identified, the default response was to try to sort them out behind closed doors without the public ever finding out.

That approach prevented rapid, decisive action from being taken. Too often managers who had failed were recycled to jobs in a different part of the country where they continued to make the same mistakes. And because of the secrecy, the wheels of change ground very slowly. Failures at Mid Staffs went on for four years before decisive action was taken. In many ways, the scandal was not that terrible things happened, but that they went on for so long before being stopped. But how could there be impetus for change when no one knew that it was needed?

After a lot of resistance from both the Department of Health and the NHS, I introduced a transparent and independent ratings system for hospitals, GP surgeries and care homes – the first healthcare system in the world to do so. Based on the Ofsted system used successfully for schools, it introduced a four-point scale for every organisation. All were graded either ‘outstanding’, ‘good’, ‘requires improvement’ or ‘inadequate’. An ‘inadequate’ rating usually led to the hospital being put into ‘special measures’ with wholesale management change.

Hospitals are much bigger and more complex organisations than schools, so underneath the overall rating were sub-ratings on safety, outcomes, responsiveness, compassion and leadership. The process of getting to a rating was a huge undertaking, with around fifty inspectors (many of whom were themselves doctors and nurses) descending onto a hospital for three days.14

The result was that in the first three years, twenty-eight hospitals were put into special measures.15 Most had their management changed and the majority then showed improvements. A few took a very long time to turn things around but, four years on, nearly three million more patients were being treated in ‘good’ or ‘outstanding’ hospitals.16

Had I stopped being Health Secretary after a year or two, I would have probably said that the key to better patient care was that kind of transparency, perhaps accompanied by targeted campaigns in particular areas like medication error or sepsis. But the longer I continued, the more I became convinced there was an even more fundamental issue that needed tackling. In medicine, we are just not as good as we need to be at learning from mistakes and spreading best practice. This was writ large at the start of the Covid-19 pandemic, when Europe and North America failed to learn from the much more successful approach taken in places like Korea and Taiwan17 – but the issues are the same in more normal times.

So I began to look at how other industries worked, including the airline, nuclear and oil industries. I read books about patient safety like The Checklist Manifesto by Atul Gawande, which have saved thousands of lives through systematising changes in behaviour. What I learned was the importance of culture change when it comes to learning from error. If the priority is punishing individuals after a tragedy pour encourager les autres, the only real consequence is backside-protecting and cover-ups. If, however, your main focus is preventing tragedies from being repeated, you need exactly the opposite: rapid, no-blame investigations and urgent dissemination of any lessons learned. That can only happen if frontline professionals feel able to speak truthfully and openly when things go wrong, as they inevitably will.

How do you get there? I start this book with a section on the core issues: a pervasive blame culture, staff shortfalls and resourcing. I then go on to look in more detail at what causes that flawed culture: an obsession with targets that can make numbers more important than people; over-rigid hierarchies; fear of litigation; groupthink; and the risk of certain groups being marginalised.

Then I look at the best solutions: restoring the doctor–patient relationship with proper accountability for every single individual in the system; transparency; smart (but not detrimental) use of technology; and prioritising prevention as well as cure. These are big topics in their own right but my focus is on how they can help to prevent avoidable harm and death. I therefore explicitly examine the challenges facing the NHS through a patient safety lens, although fully recognising that there are other equally valid ways of doing so, such as medical advances, new models of care or health inequalities.

Finally, I reflect on the challenge of implementing such solutions in the world’s fifth largest bureaucracy, including my own battle with junior doctors and the role patients have to play. I also ask whether it is motivating or demotivating to aim for ‘zero harm’, given we are unlikely ever to achieve it. In short, I look at how to reduce avoidable harm and death from every possible angle, and try to talk as much about solutions as about the problem.

This is not a memoir, but, as I examine these issues, I cannot avoid some consideration of my own record. Where I identify a problem, some will understandably criticise the fact I did not solve it despite a long time in the job – as in the tweets above. Inevitably, in a job with such responsibility you don’t get everything right, and you learn things as you go along. We should all want our politicians to do that.

Although reflecting on those six years is necessarily a subjective process, I have, none the less, tried to be as objective as I can. That includes successes already mentioned, such as the fact that by the end of my tenure three million more patients were being treated every year in ‘good’ or ‘outstanding’ hospitals. It covers failures such as the disappointing progress in recruiting more GPs and the unintended consequences of the junior doctors’ strike.

But most of the time the outcomes were somewhere in between – some progress, but much more needing to be done. The best example of this is perhaps maternity safety, where there was a marked reduction in baby deaths18 – but still levels of harm far higher than in countries like Sweden.19 Even though some will disagree with my analysis, I make no apology for presenting it: if we want the NHS to be the safest and highest quality healthcare system in the world, we should seek to learn from successes and setbacks in its history.

I wrote this book on the basis of my own experiences, interviewing many patients and families. It is told unashamedly from their point of view. I try to be fair but do not attempt to balance such stories with the alternate viewpoints of the hospitals, surgeries or clinicians with whom they interacted – that is a job for those conducting inquiries or inquests. For that reason I have not identified the names of the hospitals where such events took place unless the issues to which the stories relate are widely in the public domain.

My father worked in NHS management after he retired from his career in the Royal Navy, and my mother was a nurse during the 1950s and 1960s, about the same time as Call the Midwife. I have three wonderful children born thanks to the NHS. But perhaps my best experience of NHS compassion came more recently, when my four-year-old daughter fell off a running machine and suffered serious burns on her back.

Being with her at all hours in the burns unit of the Chelsea and Westminster hospital made me appreciate why the NHS is different: it’s not that doctors and nurses in other countries aren’t equally kind – anyone who goes into medicine chooses to make caring for others central to their life. But unlike other systems, because the NHS does not bill people directly for their care, we are always patients and never customers. That means the compassion you experience is never generated by a financial motive and is always utterly genuine.

I think that is why so many people talk about the quality of NHS care with a certain awe. It is why the British have taken the NHS to their hearts. But with 150 avoidable deaths every week – even outside a pandemic – how often does our system support doctors and nurses to demonstrate the compassion my family experienced – and how often does it frustrate them?

Part One

The Three Big Causes of Avoidable Harm

1

Blame

As Health Secretary, perhaps the most difficult meeting I ever had was on 2 March 2015. It was the day before I had to give a statement to parliament on the Kirkup Inquiry into baby deaths at Furness General Hospital, part of Morecambe Bay Trust.1 The meeting was with a group of families who had lost their babies due to poor care at the hospital. They were angry and wanted justice and closure. What made them most angry was that some of the staff allegedly responsible were still working at the trust. I had a lot of sympathy – but as I dug deeper I came to a rather unexpected conclusion about the motivations of the staff involved, namely that they were more likely to have been scared rather than evil.

Simon Davey and Liza Brady had lost their son Alex, who was stillborn. An inquest discovered failings in his care by midwives, who did not involve doctors early enough during Liza’s labour.2 A subsequent report by the Parliamentary and Health Service Ombudsman pointed to the poor supervision of midwives.3

Carl Hendrickson lost not just his son Chester, but his wife Nittaya too. She suffered a rare embolism after giving birth to Chester and died within an hour. Chester had brain damage and passed away the next day. Important heart monitor documents were lost, along with other hospital emails. The midwife responsible for the birth had dismissed Nittaya’s fits as fainting.

Ahead of the meeting, my staff told me that Carl had brought his eleven-year-old son Conrad with him. I asked them to offer to look after Conrad during the meeting, as it would be likely to cover pretty difficult subject matter. No, the reply came, he insists he wants his son to be with him at the meeting. Carl later told a newspaper that was because he thought, ‘You’ve lost your mum and brother, and when you grow up I want you to know that I took this to the top man in government, and that we asked some awkward questions.’4

Carl and Nittaya Hendrickson

Awkward questions were exactly what those families asked. How could staff involved in such incidents still be working in the same maternity unit? Why did the trust cover up what had happened for so long? Why did the NHS not launch a proper national inquiry sooner? The sense of injustice was palpable, and I felt deeply ashamed of what had happened to them.

Because they had been forced to fight so hard for the truth, I felt I needed to be totally honest about what I could and could not do. That would include saying things they might not want to hear.

‘If this was a dictatorship,’ I said, ‘and I could stand in parliament tomorrow and say that all the staff involved have been fired forthwith, that might give you satisfaction. But what signal would it send to maternity staff in another hospital, the next time something went wrong? Might they decide the safest thing was for them, too, to cover up their mistakes?’

The covering up of mistakes is endemic. Not just in the NHS, but in most modern healthcare systems. It arises because, in the justified quest for accountability – particularly for something as serious as when a patient dies – reputations, careers and money are at stake. But how do you square the need for accountability with the need for space to learn from mistakes – even the gravest of mistakes, which lead to loss of life? In the end, that is the key to eliminating the 150 avoidable deaths we have every week in England.

So how do you replace a blame culture with a learning culture? In this opening section, I will look at the main causes of avoidable harm and death: a flawed culture, workforce shortages and resources. Because the latter two are discussed and debated endlessly (at least in the UK), I then spend the next section looking in more detail at the root causes of poor culture in healthcare workplaces, before going on to consider solutions.

But first, let’s look more carefully at the issue of blame. Why does it get in the way of making improvements that absolutely everyone wants to make?

James Titcombe is perhaps the UK’s best-known patient safety campaigner, and his focus has always been on getting the culture in healthcare systems right. He differentiates between a ‘just culture’ and a ‘blame culture’. His own life was shattered by the loss of his son, Joshua, after he was born at Furness General Hospital. He wasn’t at the March 2015 meeting because we had already met – in fact, he was the person who had persuaded me to set up the Kirkup Inquiry.

The first time I met James, I was struck by his combination of calm modesty and inner steel. He worked as a nuclear industry project manager at Sellafield in Cumbria, and exuded the quiet pragmatism you would expect from someone who knows what it is like to be responsible for life-and-death decisions. But as he sat in the beige armchair in my office and began to tell his story, I could see that alongside that calmness he had extraordinary determination to find out the truth about what happened to his son.5

Everything had started with such promise. At around 5 a.m. on an October morning, his wife Hoa’s contractions began. The hospital advised him not to bring her in until the contractions got more frequent, which they did – quickly – and by 6.30 a.m. James and Hoa were in the car to Furness General Hospital.

As a project manager, James was a natural planner. So before they left home, he carefully made sure the cot was ready in the house and a car seat for the baby in place. But as he started the engine, he never imagined he wouldn’t be bringing his wife home for two weeks – with both their lives irreversibly scarred.

After a short labour, Joshua Titcombe was born at 7.38 a.m. He was blue, floppy and appeared not to be breathing. The midwife took him straightaway to another room for an oxygen blast, after which he let out a loud cry. Everyone relaxed. The new mum and dad had tears of pride in their eyes.

Then Hoa became very ill with a ragingly high temperature. James called for help, and eventually she was given antibiotics and fluids for an infection. James wondered: if she had an infection, did Joshua too? But the midwives dismissed any concerns. The baby was fine. As a layman, the new father accepted their advice. That night, James went home relatively relaxed. Joshua was supposedly fine, and Hoa was getting the treatment she needed.

Later, however, Joshua became visibly ill. He was cold and grunting. At one point, in the middle of the night, he was making such loud noises that Hoa rang the bell by her bed. A midwife came in and took Joshua away for half an hour, before returning and telling Hoa that he was fine.

But the midwife did not consult Joshua’s notes, including the yellow observation chart that would have shown his temperature was abnormally low – a classic sign of sepsis.6 Nor did she consult a doctor. Those temperature charts subsequently went missing – never to be recovered.

The reassurance turned out to be false – and shortly afterwards Joshua deteriorated. James was called back to the hospital. He arrived to find his wife in tears and Joshua being looked at by a doctor in a different room. James got one glimpse of his son before he was told to leave. Standing outside, he saw a team of medics gather round as Joshua was put on a full ventilator, no longer able to breathe with his own lungs.

Surely, James thought, Joshua hadn’t collapsed from the same infection as his wife? Not when he’d raised the issue so many times and been reassured to the contrary?

But admitting they had got the diagnosis wrong was too much for the staff, so this time James was told that it looked as if Joshua was suffering from a heart defect. Later, this untruth would be finessed as a ‘differential diagnosis’, a snap judgement made in the heat of the moment. But James was starting to lose faith in the system.

Finally, Joshua was put on the antibiotics he should have been given at the outset. But it was too late. Joshua had sepsis, just like his mother. If he had been given antibiotics at the same time as her, he would have had a 95% chance of survival. Now it was touch-and-go.

The little baby was rushed to a specialist hospital in Manchester at 11 p.m. He received extremely professional care, and James and Hoa were advised it might be appropriate to put him on an ECMO, a heart and lung machine for babies, which would allow Joshua’s heart and lungs time to rest while the doctors reoxygenated his blood artificially.

Joshua Titcombe with his sister Emily

After careful deliberation, the parents gave permission for Joshua to be flown by helicopter to the Freeman Hospital in Newcastle. Again, the care was excellent. Over the next few days Joshua appeared to make good progress, and the consultant overseeing his care decided to wean him off the ECMO machine. James went to bed that night thinking that the next day Joshua would be breathing with his own lungs. He began to allow himself to imagine bringing his baby home, the car seat ready and the nursery and cot still in place. His parents would be there to welcome the new arrival to the family.

But when James and Hoa went in the next morning, it was clear that something had gone terribly wrong. The weaning process hadn’t worked. Worse still, the doctors had discovered that Joshua’s lung was more necrotic – rotten – from the sepsis than they had realised. Over the next twenty-four hours, the team at the Freeman Hospital did everything they could to try to keep Joshua alive, but his situation became ever more desperate.

The next day, when the consultant came to see them, James knew instantly.

‘He’s gone,’ he said, ‘isn’t he?’

The consultant nodded.

They went in to say goodbye to their son. The nurses had taken out all the tubes and removed the equipment. As James told me, ‘He just looked like the perfect baby boy.’

A couple of years after Joshua died, my own son was born. ‘There but for the grace of God,’ I thought, as I listened to James tell his story. I sat with tears prickling my eyes, wondering whether this kind of thing was still happening in the health service for which I was responsible.

If James Titcombe had not been a project manager in a safety-critical industry, what happened next with the Morecambe Bay trust – indeed, the history of the modern NHS – might have turned out very differently. But because of that professional background, with his logical mind James started to make a list of all the things that had happened throughout Joshua’s short life, starting with the yellow observation chart that went missing. His extraordinary battle to find out the truth lasted six years, involved the police, the courts, the senior leadership of the NHS and me as Health Secretary. James thinks he wrote over four hundred emails and letters to get to the bottom of what happened.

Mistakes are inevitable in any healthcare system. The NHS, after all, treats over one million people every thirty-six hours.7 So what shocked me about James’s story was not the existence of a mistake (even a tragic one), but the resistance to telling the truth about it to a grieving parent. To understand the lengths people will go to avoid the risk of being ‘blamed’ for a tragedy, it is worth looking at what James then experienced.

He started by writing a letter to Furness General Hospital. He hand-delivered it, doing everything he could to make sure it was read by the CEO. He expected all the stops to be pulled out to understand how something so catastrophic had happened. That would have been done automatically in his workplace in the nuclear industry, or indeed with many consumer complaints that were a thousand times less serious.

In fact, the opposite happened. James learned about one of the saddest ironies in modern healthcare, namely that the greater the catastrophe, the greater the temptation is to gloss over what really happened. People in hospitals are human, and they are busy. Everyone is devastated when a child dies, but that child cannot be brought back to life. So professionals often mask their discomfort about getting to the bottom of what happened by focusing their energies on patients whose lives can be saved – and sometimes allowing grieving relatives to be dismissed as unhinged or unbalanced.

James would hear reports of people saying, ‘He is still coming to terms with what has happened’ or ‘There is nothing we can do or say that will make him better, he just needs to go through the grieving process.’

But James wasn’t asking for anything more than an honest account of what happened and some reassurance that the same mistakes would not be repeated. He was met with a brick wall. The coroner refused to open an inquest, saying that Joshua had died of ‘natural causes’. James pointed out to no avail that although a necrotic lung was a natural cause of death, the reason the lung became necrotic was not.

Initially, James was not even allowed to see the statements made by clinicians during the hospital’s own inquiry, although he eventually forced the hospital to release them. Those statements had numerous inaccuracies. They said Joshua was pink and cried immediately when born, when in fact he was born blue and not breathing. A midwife stated that she had phoned a paediatrician for advice about Joshua, had fully informed him of Joshua’s circumstances, and was told that he didn’t need to be assessed – but all the paediatricians on duty that day denied such a phone call took place.8

He then went through the hospital’s complaints process. Morecambe Bay said they would treat it as a serious incident and get clinicians from another trust to do a ‘serious incident review’. But the process dragged on and the report, just seven pages, didn’t emerge until three months later. It did acknowledge that Furness General had failed Joshua and that staff should have recognised Joshua’s fluctuating temperature as a sign of sepsis.9 But it didn’t scratch the surface of what actually happened.

James eventually found out the full story. After exhausting the NHS complaints process, he finally persuaded the coroner to change his mind and open a full inquest. The final report was damning, accusing the midwives of collusion. James was able to prove this by uncovering a document all the midwives had used to prepare for the inquest, coaching them on the precise words and phrases to use. The coroner said it was inconceivable that eleven different midwives, all trained in different places, could claim blanket ignorance of a basic piece of knowledge, such as that a low temperature was a symptom of sepsis.

On the morning of Joshua’s funeral, James went to buy some flowers. The florist asked him why, and told James her own baby had also died at Furness General. ‘Just one of those things that happens,’ she was told. Far from Joshua being a ‘one off’, as James was told, his death was the fifth incident of its kind at the hospital. Had the hospital been transparent and learned from what happened the first time, Joshua would probably be alive today.

Once it became clear there was a more systemic cover-up, James approached me as Health Secretary to ask for an independent inquiry into maternity services at the hospital. Our meeting nearly didn’t happen, because, as I later learned, civil servants were reluctant for it to take place. Not because those officials weren’t decent, compassionate people – but they, too, had become part of the system’s defensiveness.

I agreed to meet James and to his request for an independent inquiry. I appointed Dr Bill Kirkup, an experienced obstetrician, to head it up. When his report was eventually published, it confirmed the worst fears of many families. It listed a catalogue of failings including dysfunctional management, a board completely unaware of and uninterested in what was going on, a working culture that discouraged openness, and poor oversight by the wider NHS. Up to eleven baby deaths were assessed as having been preventable.

It also became clear that a desire to sweep problems under the carpet extended well beyond the Furness General Hospital and the Morecambe Bay trust it belonged to. Professional bodies such as the Nursing and Midwifery Council (NMC) appeared to close ranks to protect the midwives involved. The Parliamentary and Health Service Ombudsman, set up to be the call of last resort, also failed to spot the issue. It was as if everyone in authority and every organisation was lined up against a father who just wanted to know why his son died.