Another sad story of toxic culture – A failure to learn from avoidable medical mistakes

It is unsurprising that there is a call for the Crown Prosecution Service to bring corporate manslaughter charges against Shrewsbury & Telford Hospital NHS Trust following an apparently damning report which looks at the culture of the Trust which has led to maternal deaths, stillbirths, babies left brain damaged because the staff failed to realise labour was going wrong or that Group B streptococcus or meningitis was present which required treatment by antibiotics. 

Although the call for the involvement of the criminal law is understandable (and in this case may be appropriate) it is a reaction to an avoidable situation (https://www.bbc.co.uk/news/uk-england-shropshire-50472199). The risk of using the criminal law is that parties become deeply entrenched and the key to finding solutions to prevent another scandal might be lost.  This must not be allowed to happen. 

One parent observed that the Trust “wilfully refused to learn from earlier cases dating back decades”.  She also said “no other baby will suffer the same harm while I have breath in my body”.  Elsewhere the environment of the Trust was described as “toxic”.

This report really does make desperate reading and extreme responses to such a catastrophe are inevitable and therefore there may well be a groundswell of public opinion that corporate manslaughter charges should be brought but, beyond that, it seems to me that there are three elements that need to be looked at to avoid a future recurrence:

• Toxic cultures - These must be identified, named and called out.  Usually when you scratch below the surface of a toxic culture there is bullying, cover up and blame.  The news report identifies that the interim reports said the number of cases “seem to represent a long standing culture…that is toxic to improvement effort”.  Which brings me on to the second point.
• The failure to learn from errors – This almost by definition means that there will be a recurrence when this is a long standing problem.  Inevitably failures affect morale and performance. 
• The voice of the patient and the patient’s families - It is likely, with the numbers of incidents that are being reported that there are a series of patient stories relating to the Trust that, had they been listened to, would have helped achieve the cultural shift required to move this under-performing Trust on.

My colleague has previously written about this investigation and report and I have argued elsewhere about the importance of the patient narrative and the need to use the patient narrative for learning.  When I read “that is why I fought every body and every institution in Kate’s name because no other baby will suffer the same harm while I have breath in my body” it is heart breaking that, once again, a patient narrative has been heard too late to save this parent’s child and it has fallen to distressed and bereaved parents to insist on accountability when it should be an organisational responsibility to learn from mistakes.

Further information

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