So, what, then, in addition to avoiding complacency, are these lessons?
Complacency is the enemy of safety
The start of the chapter on “Lessons to be Learned” is very powerful.
Sir Brian explains that it's clear from the first chapters of the Inquiry report onwards that most infections could and should have been avoided. It's clear that mistakes were made. The way in which institutions, and particularly the government, reacted to what had happened after 1985 was in many respects shameful. This should never happen again. The first step in deciding how best the mistakes of the past can be consigned to the past, and kept there, is to understand the lessons to be learned from what happened. One of the lessons is that wishful thinking is all too easy and should be avoided. It would be wishful thinking to suggest that because we can now see what combined to cause the greatest treatment disaster in the history of the NHS and recognise steps that need to be taken to guard against it happening again, that something similar will not do so.
To ensure the greatest possible safety, we need to avoid complacency. There is no basis for assuming that threats are all in the past: but watchfulness and learning the lessons of what happened in the infected blood disaster are critical to this.
- What happened wouldn't have happened if safety of the patient had been paramount throughout.
- One of the lessons to be learned from the Inquiry is that everyone has a responsibility for patient safety – from the government, whether in the departments of health, or as responsible for the NHS, or as the licensing authority; the blood transfusion services; hospital trusts and boards; clinicians; plasma fractionators; those overseeing the system and practice of medicine; and those who are professional advisers, educators or representative bodies including the General Medical Council, and Royal Colleges. All have a part to play in safety.
- Risk needs to be understood better. Few, if any, treatments come without risk. All pharmaceuticals have side-effects. All medical procedures have side-effects. Doing nothing (“conservative treatment”) may also have repercussions.
- A risk is just that: a real possibility that something might happen. It's recognition of such a risk which first calls for a response. Certainty (or near-certainty) that the potential event will actually occur (or is starting to occur) isn't required.
- To wait for more research to be done to identify more precisely the degree of risk, or identify more closely the cause of it, but in the meantime to do nothing but wait until the research is concluded, is to take far too long. The question should always be asked whether conducting research will enable the risk which is apparent to be met more easily, and in a better way: but waiting for the answer should not prevent measures to reduce that risk being taken in the meantime merely because the research has not yet been concluded
- So long as there is a real possibility that A causes B, there is no need to understand precisely how it does so before responding.
- Avoid asking the wrong question
- Risk must not be confused with incidence
- If risk exists elsewhere in the world it could still be a threat here
- Risks should not be ignored because they are though inevitable
- Healthcare professionals should take a reflective approach to risk.
- Reduction of risk is worthwhile even if full elimination of risk is not possible
- Forward planning, looking a number of years ahead, is not only desirable but is likely to be essential where capital expenditure is to be anticipated.
- No one and no body appears to have monitored failures to carry out promised reviews.
- Forward planning involves taking care not to repeat the mistakes of the past. It is apparent there has been no mechanism to ensure that there is a sufficient corporate memory in the Civil Service of why previous decisions were, or were not taken, and the facts that informed those decisions so the reasons could be understood.
- Communication means listening: It is more talking with, than talking to
- Care must be taken to communicate: Telling a patient what the professional as an expert clinician knows about
- (a) risk
- (b) alternatives
- (c) consequences
- (d) the nature of any tests to be performed and what they might show of significance to the patient
- (e) what the results of those tests have been
- (f) in particular, listening properly to what the patient has to say; hearing their worries and questions, and goals and preferences for treatment
- Communication about a treatment involving risk to the patient and potentially their family members should explain:
- (a) that there's a risk
- (b) how serious a risk it is
- (c) what steps can be taken to avoid or minimise that risk, including what alternatives are available
- (d) whether it is unreasonable, or unreasonably difficult, to take those steps.
- Communication of a diagnosis or test result should in the first instance be to the patient
- There can be no proper consent without adequate communication. Consent is not a matter of obtaining a tick or a signature on a sheet of paper, but a real process of information, discussion and co-decision.
- The clinician has the power of expert knowledge, which the patient lacks, but the patient has the power of ultimate decision, which the clinician must not usurp.
- Part of a clinician’s duty is to be able to deliver bad news to their patient, and to aim to do it sympathetically rather than by providing false reassurance.
- Candour is essential in the relationship between clinicians and patients. Both patients in accepting treatment, and clinicians in advising on it, are badly affected by its absence. Advice as to risks, prognosis, potential treatments and their side-effects needs to be realistic.
- Trust in the political system where it concerns healthcare and the NHS is essential. That trust is easily sacrificed. It needs honesty, openness and transparency if there's not to be a loss of trust which is harmful to patient care.
- Dealing with uncertainty in a system which values certainty of outcome is not easy. Sources may – and in the case of medicine and health often will – not be sure what is correct. It may be embarrassing to admit this. It is, however, even worse to volunteer a “fact” or “half-truth” when there is no proper factual basis for it; or to dress it up in misleading text.
- Medical treatment isn't selling a product nor is government in the same position as an advertiser. More is to be expected of both. The lesson to be learned is that claims for near perfection, or that what was done to a patient couldn't have been improved on (it was simply “the best”), need to have a sound basis in fact if they are to be advanced. All of us would like our treatment from the NHS to be the best that there could be, but wishing it's not the same as being it.