Thoughts on World Patient Safety Day

18 September 2019

Yesterday was 'World Patient Safety Day' and Kingsley Napley hosted AvMA's event 'Patients Speaking Up For Patient Safety' Chaired by Shaun Lintern at which the audience heard fascinating  talks from the Right Honourable Jeremy Hunt MP, James Titcombe OBE, Joanne Hughes (Mothers Instinct), Maureen Tuit (Maureen Insight Specialist Counselling Service), Peter Walsh and a short piece from me about the Cappuccini Test.

Many of the talks touched upon fear and I reflected this morning that fear is often something that precedes stigma and stigma creates secrecy.

Yesterday wise words were spoken on the need for transparency and, in particular, how secrecy stands in the way of proper learning. 

James Titcombe has campaigned to “prioritise safety over fear”. Joanne Hughes calls for a move from “wounds to wisdom”. All the speakers yesterday were calling for the barriers to be dissolved so that adverse medical incidents can be looked at in an environment that preserves the dignity of all and leads to genuine learning. 

There is a perception that the way that the law works corrupts culture in the NHS.  My thought is that the law is brought to the fore when patients are striving to discover the truth and are met with fear and a lack of transparency.  That fear and lack of transparency comes from the stigma that can attach to medical accidents. This is, in part, because of a lack of understanding of what the law is . This creates fear of the unknown that can leave medics feel isolated, distressed and even, very regrettably, shamed.  When those feelings expand to be organisational you get the locked-down environment of corporate damage limitation.

The imperative must be to seek to avoid, not fear, mistakes. Also the commitment ought to be to learn from mistakes so that they inform the healing processes of the future.  A confident Trust will be stable, responsible and accountable as well as honest.  It will have a collegial environment that uses peer pressure to drive up standards to get things done and, through co-operation, create an environment where people will go the extra mile. 

In that environment, when things go wrong, the harm should be acknowledged with objective and neutral openness. There must be a willingness to listen to and hear the narratives of all of the people involved ( particularly the patient).  The process must be de-personalised, the questions should be asked: who is hurt?  (and that should include the staff involved), what do they need?  How is  responsibility  for delivering solutions discharged and learning guaranteed and illustrated?

An environment that encourages this sort of enquiry will be constantly learning but also preserves the dignity of all.  Trust between the organisation and the public will flourish if the system delivers both compassion and accountability.  Excellence through learning from mistakes can happen in that reflective and wise environment. 

Yesterday’s talks gave many positive examples and showed that much has been done that can be celebrated. There is, however, still work to do.

If you have been affected by any of the issues discussed in this blog, you can contact us on: 020 7814 1200 or email us at


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