Red flags

Principal consultant Peter Allanson underlines the importance of heeding warning signs and developing a culture of learning.

The consequences of NHS trusts repeatedly ignoring red flags can be desperate. Those consequences are sometimes expressed across boardroom tables or in reports as failures of quality, or risk management, or assurance, or perhaps as safety incidents. But the reality is far more visceral and devastating for the patients and their loved ones on the receiving end.

In his introduction to his recent report into the failings at East Kent maternity services, Dr Bill Kirkup CBE brought this reality vividly home when he wrote: ‘The death of a baby is a devastating loss for any family. As one bereaved mother put it, “When your baby dies, it’s like someone has shut the curtains on life, and everything moves from colour to darkness.” How much more difficult must it be if the death need not have happened? If similar deaths had occurred previously but had been ignored? If the circumstances of your baby’s death were not examined openly and honestly, leaving the inevitability of future recurrence hanging in the air?’

Mid Staffs

One of the most notorious episodes in the history of the NHS was the ‘Mid Staffs’ scandal, when up to 1,200 patients died as a result of poor care between 2005 and 2009 at Stafford Hospital, a small district general hospital that was part of Mid Staffordshire NHS Hospital Trust.

In 2013, Robert Francis QC, who chaired the Mid Staffs public enquiry, said: “The information which would have led people to realise this was happening was so diffuse that no one paid attention to it. Nor did they pay attention to the little signs that could have told them as well.”

East Kent Maternity Services

Bill Kirkup’s review of maternity and neo-natal services provided by East Kent Hospitals University NHS Foundation Trust, Reading the signals, examined 202 cases that took place between 2009 and 2020, concluding that outcomes would have been more favourable in 97 of them if national standards had been properly followed by the trust. In the 65 cases of baby deaths, 45 could have had different outcomes.

In his report introduction, Dr Kirkup wrote: “It is too late to pretend that this is just another one-off, isolated failure, a freak event that ‘will never happen again’. Since the report of the Morecambe Bay Investigation in 2015, maternity services have been the subject of more significant policy initiatives than any other service.

“Yet, since then, there have been major service failures in Shrewsbury and Telford, in East Kent, and (it seems) in Nottingham. If we do not begin to tackle this differently, there will be more.”

He listed eight opportunities to improve that were missed in East Kent including failing to take any notice of various internal and external reports that should have resonated with them. Overall an abject failure to learn.

With the benefit of hindsight it seems inconceivable that a trust could fail to react to so many warnings that things were awry. And yet that’s exactly what happened – and has been consistently happening across the NHS since its inception. Sadly, we often see similar issues when we carry out investigations, both large and small: trusts failing to act on warning signs.

Both of these appalling cases highlight the critical importance of remaining focused on patient needs – and of recognising and reacting to red flags and of learning from what has happened.

And yet…very few people come to work to do other than their best for their patients. Trusts with a real appetite for knowledge, and ambition to improve continuously and an insatiable thirst for research exist and carry their staff and patients along on the back of their enthusiasm. How then should organisations develop these positive attributes?

Leading from the top

First and foremost, leadership must come from the top. In the NHS too much time and activity by the board concentrates on the past – largely things that the board is powerless to influence. What it can do is set the value and culture of the trust as it develops its strategy – looking to the future which must include learning from the past. The power of taking an appropriate interest and being clear what is important is an essential signal for a board to send out to their trust.

There are a number of other criteria that mark out successful learning organisations. The US systems scientist Peter Senge, who is the father of the term, says that a learning organisation “perhaps can be defined as a place skilled at creating, acquiring, and transferring knowledge and at the same time changing behaviour to reflect the new knowledge and insights”.

That suggests:

• The management hierarchy encourages opportunities to innovate and apply learning.

• The prevailing culture is open and creative – there is no blame (although there is of course accountability and responsibility) and mistakes are seen as opportunities to improve.

• There is facilitation of information sharing, by whatever means – ranging from written, spoken, and moving people around to experience new methods through to creating films and apps.

• Improvement and change is measured – which can be fraught with difficulty.

• Finally and perhaps most importantly, leaders model these attributes in their interactions with the executive – openness, appropriate risk taking and reflection.

None of this is easy but even if it was, the question remains: why do organisations not embrace this agenda as confidently as they arguably should?

The answer lies largely at the top of the organisation and its willingness to see this agenda as important, then to model the behaviours described and to talk about it. Too often, when we are carrying out a review, we don’t see or hear that the organisation is one with a culture of learning.

By genuinely turning into learning organisations, the risks and experiences outlined by Dr Kirkup and implicit in other reviews and investigations – including many undertaken by GGI – will be avoided, and we will begin to see an end to repeated mistakes and errors by organisations.

Are you doing all you can to spot, and act on, the red flags in your organisation? That would be a fantastic resolution for 2023!

What would we find if we looked at your organisation? Is this an area where you need support to make changes? Contact us if you’d like to find out more.