On 21 November 2018 Department of Health and Social Care published Learning from Gosport.
The response describes three types of action.
- Measures already in place and established.
- Reforms in place and developing.
- Changes where we need to go further.
With regard to listening to patients, families and staff the key actions include:
- legislating, subject to parliamentary time, to make all NHS trusts in England publish annual reports on concerns raised by staff who speak up; and
- CQC reviewing how it assesses the statutory duty of candour.
They make some powerful points in this chapter such as “the report helps us to see that ignoring the voices of patients, families and staff can cost lives”. They note a number of themes in the panel’s report that are common to other reports in recent years e.g. the quality of investigations is patchy and lessons are not consistently being learned or implemented. The Government believes that now is the time for a different approach. The Department plans to publish a strategy for improving the way feedback is managed and used in the NHS later this year.
With regard to ensuring care is safe they note that patient safety is a continual challenge and that the governance and oversight of care within a hospital is the most important line of defence against failures in care. With regard to Gosport, they note that the problems stemmed from a lack of oversight of quality and clinical governance within the hospital and the wider health system at the time. Looking at learning, they observe that gathering data is only part of what is needed and they are also taking action to ensure that there is careful analysis and pattern recognition that then leads to action. This chapter concludes with the statement: “whilst inspection and regulation are vital in identifying and addressing cases of poor or unsafe care, the best means of prevention lie in the hands of healthcare organisations and the people working in them”.
Finally, in the chapter on identifying and addressing problems in care, 11 key actions are listed. These include revision of the NHS Serious Incident Framework which we are told is “currently being revised”. Tabulated paragraphs 4.41 – 4.54 covers police, criminal justice and inquests which is a topical issue for many of our clients. The Government is to explore what more can be done to ensure that various investigations are appropriately sequenced and co-ordinated. They will look at how they can be organised so they can meet the interests of justice and are fully compliant with the relevant statutory remits whilst also recognising and addressing the concerns and priorities of patients and their families. Us lawyers get a mention here too. The Ministry of Justice is developing a protocol consisting of key principles which they propose that public bodies and their legal representatives sign up to as to the approach that will be taken at inquests when a public body is represented. The aim being to help make sure bereaved families are at the heart of the process and that the process is truly inquisitorial and seeks to identify lessons to be learned.