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Building Safer Clinical Systems

Safer for Whom?

The sad case of a child death, a manslaughter charge and two careers in ruin should cause every doctor to at least pause, catch breath (ironically not so easy to do today) and consider their own circumstances and service. However, an age-old mindset leaves patients perhaps a little safer and yet the doctors responsible for their care more vulnerable than ever.

On that fateful day, now years ago, a by all accounts high-flying ST6 paediatrician with an unblemished record recommenced her last part of training after maternity leave. The appropriate term for what she re-entered might just be a warzone and warzones leave casualties. This case is littered with them, from six-year-old Jack, to his parents & relatives, to the ST6 Paediatrician, to the agency nurse and even the Trust.


Hadiza was left covering too many areas without remotely enough support. It’s easy with hindsight to say that she should have said ‘no’ and ‘forced’ the Trust to address the issues it was facing that day in a manner that protected both staff and patients. She was an ST6. She should have gone to her consultant. Her consultant was not there. It’s easy then to move the pointed finger through ninety degrees. Or is it?

Culpability is remarkably complex in the NHS. How do we separate culpability in the moment from systemic culpability. Is it Hadiza’s fault for not saying no, the Trust’s fault that they had her working in these conditions, Health Education England for poor workforce planning leading to shortages of paediatricians or the fault of the DHSC and Treasury for not ensuring enough funding? Of course, the answer is ‘yes’ to all of the above but the higher you go, the more defuse culpability and thus the less likely a ‘body’ will be held more responsible than an individual. And that brings us to individuals…

We look for individuals who are responsible. The doctor and nurse at the point of care where the mistakes were made are the individuals where arguably culpability is easiest to evaluate, even if that evaluation seems grossly unfair when other factors are considered. The GMC have added to that list with the assertion that Hadiza should have gone to her consultant or service lead and their own subsequent actions would have a bearing on both theirs and her culpability from that point onwards. It gets very messy when we start to consider the increasing numbers of cases where juniors feel unable to raise concerns or where there is a poor mechanism for doing so.

The Mindset and the Moment

I mentioned a mindset. It’s actually three concurrent mental traits or tendencies present in the majority of doctors that leaves you increasingly vulnerable. Let’s get them onto the table:

  1. The tendency to want to pull together and just get it done
  2. The tendency to act with steady-handed caution, so as not to over-react
  3. The tendency to (often unwittingly) place patient safety above the security of selves

The GMC is clear. Find yourself in those circumstances and there’s a line of accountability and escalation that must be climbed. However, for all that clarity, it fails to remotely deal with human mental frailty. The sorts of challenges causing so many problems (and medical vulnerability) being:

  • Conditions are rarely so clear cut
  • They tend to develop (creep up), much like a growing storm
  • Consultants are often facing a myriad of concurrent storms
  • Battening down the hatches too early also has the potential to cause harm
  • If you are mid-ocean when the storm hits, a safe haven doesn’t appear available – the point being, you’re in the maelstrom and little is going to change that fundamental

Finally, with so many things to sort, the majority of consultants or service leads struggle to give ’emerging’ problems the necessary attention until they are unignorable. However, at that point, it’s you who is vulnerable too. The effects of all these are to virtually guarantee that the right action is only considered with hindsight. The hindsight trap is that everybody would have done it differently themselves. Except would they? In the moment? With all hell breaking loose?

It’s very clear that the mindset in use by most consultants is best suited to an era long past. Patients expect perfection and yet care is more complex and overwhelmed, in a system that is so clearly under-resourced. Nurses are voting with their feet. Doctors are obviously more reluctant to and so, in staying, that mindset needs a big update.

New Era Clinical Systems

If our mental systems need Thinking 2.0, then so do our clinical systems. Few doctors get to consultant level without training and exposure to Clinical Governance and safety systems of one sort or another. But when were they conceived and when were they revised? And did they ever place doctor safety at their heart, as opposed to a clear focus on patient safety?

The answers need careful thought because it’s individual like Hadiza Bawa-Garba who are so clearly vulnerable, and her consultants too, individuals perhaps just like you? We need to redevelop clinical systems so they are fit for purpose today. They need to be sensitive but pragmatic. They need to balance the needs of the patients with the security of the individuals at the point of care.

Better systems need to identify tough, modern-day scenarios and work through how they should be approached. What needs to happen when? When circumstances are anything but ideal, and all hell is breaking loose, what’s the best fit response? Planned escalation and responses need reality testing, if they are to overcome the mindset issues already raised. I doubt that anybody in paediatrics in Leicester would challenge that need but I wonder just how many have watched the news unfold whilst falling into one of two common behavioural traps:

  • Thinking it happens to other people in other services
  • Intending to review your clinical safety systems but just not getting round to it

The test is easy. Ask yourself two short questions;

  1. What was my reaction at the time I first heard?
  2. What have I actually done since?

Your answer to the second one probably tells you everything you need to know about potential vulnerability. Perhaps today is the next best time to start.




8 responses to “Building Safer Clinical Systems

  1. Very sobering, I have followed this tragedy since it unfolded in the news to the sorry end. I am appalled and saddened by the GMC action. WE need to take the airline industry approach to learning and improving a health care system which requires systemic emergency treatment to save it in some bits. We are approaching indications for ECT and cardioversion treatments !!

    1. Couldn’t agree more. The GMC were also in a difficult place too, constrained by rules they too are discovering aren’t suited to the complexity of today. One would hope that if you discover this that you seek to change the rules as a starting point, not a reflection.

  2. Hi Andrew. Many senior doctors look at the current situation and just get things done because if they don’t then their patients suffer and in some cases may actually die. Forcing patients to use the ‘system’ as it stands in some clinical scenarios is giving them a terrible experience and putting their lives at risk. So I am dammed if I do and dammed if I don’t. The GMC is flatly refusing to deal with reality. If every consultant in the country were to work to rule, to use pathways that simply don’t work in order to protect themselves the NHS would collapse. I am facing a set of very uncomfortable choices about care that works and the awful care quality pathway that I should use for my sick patients. Sure the Trust is aware, but sorting things out needs investment and multiple job plan changes but leadership is a joke and I cannot bring myself to cause such so much suffering to so many patients and also fear the accusation that I have used my patients as pawns in a cynical resources game.

    1. Think this is an all too common reality, very sadly. There is a perverse inequity too that pathway changes are often ‘supported’ on very suspect consultation, in which the public are pseudo-consulted on bland, bias statements and yet when professionals with 20+ years experience of caring for real patients, actually going through pathways, suggest the pathway is neither good service nor good quality, ‘they’ apparently are bias and self-interested. Apologies for the soap box!

  3. Dear Andrew

    We need to look after the profession more than ever, if we find that doctors feel they are unable to continue to work in such unsafe NHS institutions, the patients will suffer even more.
    The old firm structure at least provided the junior doctor with a sense of belonging to a team and offered patients more continuity of care. The shift system for junior doctors can be very isolating.

    1. Absolutely true. I think the other loss is that with shifts and rotas etc etc it is difficult to get the same sense of trust in your staff. This makes it much more difficult to differentiate between concerns that need addressing urgently versus ‘noise’ in an overly-busy system.

  4. Does any one think that a safer clinical system can be built with presently available resources, with blame culture increasing, though not admitted explicitly, population expecting the undeliverable, the tabloids fanning the fire just to sell more, organisations still showing subtle signs of discriminations? As a retired consultant I feel the NHS has gone downhill in the last thirty odd years from one of exemplary service organisation with dedicated staff to an organisation with demoralised overworked staff driven by administrators who are interested only in ticking boxes to please the politicians.

    1. Hi… I think that it is precisely because of the current system conditions that we must build safer clinical systems. I think what you are saying is can we expect to uphold safety under this level of pressure. To that, the answer is most certainly not everywhere, not all of the time. The Bawa-Garba case has brough to light that despite this, clinicians can no longer feel personally safe working in an unsafe system. For that reason, we need to re-define the way the system works from individual and service level up to ensure that at any given level of patient risk, staff are more protected providing they operate within the rules of that system. I think Bawa-Garba was simply doing what the majority of doctors would do in similar circumstances – trying her best to cope for the benefit of patients and the team. That wasn’t safe for any of those, including herself.

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