Every investigation into an avoidable death is a learning opportunity for Trusts, clinicians, families, wards, patients, management, boards and the community. The lessons learnt can be passed on to other organisations and future generations. But unfortunately, often investigations are done in order to not find any deficiencies. They are defensive in nature rather than exploratory. They are reductive and analytical (Root cause Analysis) rather than holistic and empathic. Both approaches bring value to an investigation but often the greater good that can come out of them is overlooked.
200 avoidable deaths take place within the NHS every week. Each of them holds valuable lessons for the future but they are buried. Hence the same mistakes happen over and over again, costing more and more lives. In some organisations serious near-misses are recorded as ‘no-harm caused’.
We need collective intelligence, not individual genius. We need responsibility and accountability, personal and professional, shared and individual.
In 2015, a report was leaked to the BBC from Southern Trust that looks after 45,000 people. They had 1454 unexpected deaths over a 4 year period, 2011-2015. Of those, just 195 (13%) were treated by the trust as serious incidents requiring investigation. Deaths of adults with mental health issues were most likely to be investigated (30%). For those with learning disability the figure was 1%, and among over-65s with mental health problems it was just 0.3%.
“To err is human, to cover-up is unforgivable, to fail to learn is inexcusable.”
– Sir Liam Donaldson.
Ref: NHS Failure to probe deaths: Shocking: http://www.bbc.co.uk/news/health-35061716