![]() He said problems of accountability extended to the top of the system. “We need a cultural change, which begins with the recognition that the current duty of candour and whistleblowing legislation simply does not work and needs replacing and strengthening,” said Mr Behrens. ‘Problems of accountability extend to the top’ However, the latest report criticised widespread failure to comply among trusts. The Francis Inquiry findings ushered in a new legal duty of candour to patients. The most recent staff survey found that nearly 40 per cent did not feel safe to speak up about clinical concerns in their organisation, while nearly half said they believed that even if they had spoken up, their organisation would not have addressed their concerns. He later died of a cardiac arrest, witnessed by his mother. In another case, 44-year-old Christopher Walmsley was given a diagnosis of pneumonia despite showing no symptoms of this, but rather symptoms of pulmonary embolism. ![]() In one clear case of a cover-up, the report said the NHS trust “did not disclose” that different assessors had given contradictory opinions on whether a delay to an operation had resulted in avoidable harm, and then did not tell the family. The report followed a snapshot survey of 400 serious health complaints in the last three years, including 22 cases of avoidable death. It acknowledged that greater spending on the NHS would help improve patient safety. These were failures to make the right diagnosis, delays in treatment, poor handovers between clinicians, and a failure to listen to patients’ concerns or those of their families. The Ombudsman found four broad causes of preventable physical harm to patients. Four broad causes of preventable physical harm “I think this has a dark side to it which I think it’s only fair to reflect on, and that is that, in some cases, it leads to arrogance, a belief that people can do no wrong”. “You can call it what you like, but it is a cover-up.”ĭr Bill Kirkup, a renowned independent investigator of medical malpractice, blamed a “toxic culture” in parts of the NHS that resisted admissions of mistakes. “Patients have been lied to, their care plans have been altered after they died. “There is no point pretending that everybody is good and does the right thing. He added: “Of course there is a culture of cover-up. “But the NHS seems unable to learn from its mistakes and we see the same repeated failings time and time again.” Rob Behrens, England’s Health Ombudsman, said: “Every time an NHS scandal hits the front pages, leaders promise never again. Pre-pandemic, NHS England estimated that there were around 11,000 avoidable deaths each year due to safety issues. ![]() It said this was driven by a “deficit of accountability and compassion” among staff, which prevented the learning of lessons. ‘Still too many preventable tragedies’Īlthough it acknowledged significant progress in patient safety, its authors concluded that “we are still seeing too many preventable tragedies”. The new report comes 10 years after the publication of the Francis Inquiry into the deaths of hundreds of patients at Mid Staffordshire NHS Foundation Trust between 20. The Parliamentary Health Service Ombudsman said patients and their loved ones who have suffered clinical mistakes often then suffer additional hurt from the process of finding answers. The investigation also found evidence of staff deleting and falsifying care records after an avoidable death. A “culture of cover-up” is leading to avoidable NHS deaths, with hospitals unable to learn from their mistakes, the Health Ombudsman has warned.Ī major new report found a “defensive and insensitive” culture when patients or their family seek answers following medical errors, with hospitals “routinely” failing to accept their errors.
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