The government has published (16 July 2015) Learning not Blaming, its full response to the Freedom to Speak Up consultation, the Public Administration Select Committee (PASC) report on investigating clinical incidents in the NHS and the Morecambe Bay Foundation Trust Investigation.
Jeremy Hunt told Parliament today that when things go wrong “they will no longer be swept under the carpet” and that the NHS must “listen, learn and improve”.
The Morecambe Bay Investigation was established by the Secretary of State for Health in September 2013. It was set up in response to a series of maternal and neonatal deaths at the Trust between January 2004 and June 2013. Mr Hunt thanked the expert panel members, led by Dr Bill Kirkup, and in particular thanked the families who pushed for the independent investigation on maternity failures at Morecambe Bay.
Actions to ensure such failings never happen again include:
removing the Nursing and Midwifery Council’s current responsibility for statutory supervision in the United Kingdom, moving to a model of professional supervision similar to that of other health professionals
a full-scale review into current maternity services and provision across the country, which started earlier this year, led by Baroness Cumberlege
He also accepted the PASC report recommendations, which includes setting up a new independent NHS patient safety investigation service to begin in April 2016.
The Health Secretary said:
Modelled on the air accident investigation branch used by the airline industry, this will be central to the ‘no blame’ learning culture which has led to dramatic safety improvements in aviation – and it will do the same for healthcare.
PASC, which scrutinises the work of the Parliamentary and Health Service Ombudsman (PHSO), conducted this review due to increasing concern that some of the PHSO adjudications have not been based on reliable evidence.
To ensure everyone in the NHS feels confident and supported to raise concerns Mr Hunt committed to a number of measures from the Freedom to Speak Up review including:
- a national ‘whistleblowing’ lead to be located in the Care Quality Commission
- ‘Freedom to Speak up Guardians’ to be appointed in all local NHS organisations
- whistleblowing training for all healthcare workers
The Freedom to Speak Up review was announced on 24 June 2014 by the Secretary of State for Health, and was led by Sir Robert Francis QC. It was an independent review into creating the open and honest reporting culture in the NHS.
The government has also published its response to the report by Lord Rose, ‘Better leadership for tomorrow’, and announced that responsibility for the NHS Leadership Academy will transfer from NHS England to Health Education England.
This announcement formed part of a wider package of announcements today, in a speech in which the Health Secretary set out his ambition for an NHS with patients at its centre.