10 Year Anniversary

I only hope lessons have been learnt from Mid Staffs

Ten years ago today my mother, Bella Bailey, died on ward 11 of Mid Staffs Hospital. In her final days she suffered horrendously at the hands of those who should have cared for her. What I saw on that ward will stay with me for the rest of my life.

It is a story I have told many times over the last ten years and while patient safety has certainly been put on the agenda the sad fact is that so little has actually changed.

With a workforce crises looming, many fear including myself that we will return to those dark days of Mid Staffs where patients were forgotten and balancing the books, the priority.

Losing my mum hit hard and still does. She just shouldn’t have suffered the way she did. I still have so many unanswered questions, something I share with thousands of families who have also seen loved ones suffer poor NHS care.

The problem is when you don’t get those answers you find it difficult to ever get over that loss. “Move on.” People say, but how can you move on when you don’t even know what happened, when you don’t even know what you are moving on from?

It is not unusual for the process of an NHS investigation to be as traumatic as the event itself. There has been no real development of the NHS complaints and investigations process since the Mid Staffs scandal was first uncovered. This must change.

Mistakes happen. Medicine is a risky and often experimental field. But we must not be afraid to do all we can to eliminate those mistakes and identify the reasons why they occur. A thorough investigation should recognise what went wrong,

before exploring all possible solutions. Once a suitable solution has been found this should be shared with the wider NHS to foster a culture of growth and learning. The NHS does not do this well. Neither does it do listening to patients well, to find out what went wrong in the first place.

I would not deny that some progress has been made. In the Mid Staffs Public Inquiry Robert Francis found a culture of only talking about the positives rather than any critical analysis. Those days have gone. And this is a significant development – as any addict will tell you, the first step towards recovery is admitting you have a problem.

Mid Staffs put patient safety firmly on the agenda and I must commend the Health Secretary, Jeremy Hunt, for his commitment on this issue. It is a cause he has pursued with far more vigour than any of his predecessors.

I sat through 137 days of the Mid Staffs Public Inquiry, listened to all the evidence and read every witness statement. I was disappointed that there was over 200 recommendations.

Cure the NHS, had around 25 which I thought was manageable and attainable. The Health Secretary told us to expect to get around 80% implemented. I am still waiting.

One recommendation I have consistently proposed is a level playing field when it comes to regulation. We have regulators for nurses and doctors but not managers. It was managers who made most of the decisions that led to the harm of patients at Mid Staffs, yet unaccountable to any regulator.

We are increasingly relying on health care assistants to care for our most vulnerable, yet they are unregulated. There is basic training in place now but sadly I don’t think it is enough. I hear of nurses struck off the nursing register then going on to work in a more isolated role as a HCA. We await the introduction of the nursing associate role, will this be regulated because it should

be? I hope the role won’t replace the registered general nurse on our wards, as that will be a step backwards.

A Quality and Safety management system has been introduced in other sectors successfully, namely the airline, nuclear and construction industries. I personally think the NHS needs more standardised procedures and I believe it would help other hospitals to emulate places like the Salford Royal Hospital in the pursuit of excellence.

Safe staffing levels go without saying and it is sad that still today, boards have no idea how many staff and the skill mix they should have on each ward. In most of the investigations I see, being short of staff or having the wrong skills mix is an important issue. This was an important recommendation by Sir Robert Francis himself. For guidelines to be developed on the numbers of nurses required for safe levels of nurses. Something that went so badly wrong at Mid Staffs. He recommended the task was given to National Institute of Clinical Excellence, which it was but the plug was pulled on the work before its completion. A decision that made me ill, as without safe staffing levels patients are likely to suffer, staff too. Which is what happened at Mid Staffs.

I was disappointed by Sir Robert Francis’ ‘Freedom to Speak Up’ report in 2015. While he detailed the problems that whistle blowers face, he provided no solutions or strategies to overcome those obstacles. Once again nobody was held accountable for silencing whistle blowers that he heard from, some of which have had their lives ruined by those who remain as leaders within the NHS.

We now have the national guardian and local guardians within every workplace. Not to mention a scheme to help whistle blowers back into work. The initiative should be monitored closely, as the NHS has a poor record of auditing what it introduces as a solution to a problem.

However we must be honest- an organisation that has whistle blowers is a failing one, as was Mid Staffs. Employees should be able to raise concerns freely within any workplace particularly around safety. We will know when we have the right culture in the NHS when raising concerns from patients and its staff, is welcomed.

The failings at Southern Health Foundation Trust recently, lead me to believe that we still have a long way to go. Governors at the hospital tried to speak out but were labelled as trouble makers, just as I was in 2007. Once again it was families who had to raise concerns and battle to be heard.

In fact it is a struggle for anyone to report poor care in the NHS. To this day I have never met anyone who has had a positive experience of the NHS complaints process. It places an undue amount of stress and anguish on people who have already been through so much.

There is nothing wrong with the current NHS complaints process per se. In fact the process itself is very similar to the John Lewis partnerships, which is claimed to be one of the best in retail. It was introduced in 2008 and replaced the 3 tier system where complainants could go to the Health Care Commission (HCC) if they weren’t happy with the hospital’s response.

Before that it was a panel system where members of a community, such as a GP or other local figures, looked over complaints outside of the hospital.

Some say it was a much better system. Hospitals criticised it on the grounds that it could delay learning but the public thought it a more independent and a more supportive system. We had Community Health Councils which felt more responsive and personalised to assist complainants. Although Wales still have them, most are now ineffective.

“Making Experiences Count,” was about local quick resolution, listening to the complainant, learning from the complaint and offering support, through the Patient Advice and Liaison Service (basically the hospital itself) and the odd advocacy service. It sounds wonderful but in practice it is still infected with the culture of denial and lack of independence, we so often face.

I must admit I have seen some very thorough investigations done by the Health Care Commission. You only have to look at the 1st report that came out of Mid Staffs, it gave us the evidence we needed to fight for the public inquiry.

Investigations now within the NHS are very ‘Hit and Miss’ and, worse still, I feel any learning isn’t spread through the system. NHS staff need to feel safe to make mistakes, until then little will change. Until we embed a learning culture, we will go on making the same mistakes. It is all about changing behaviours.

It is not the process that I regard as the problem. Rather it is the behaviours of those involved.

I so often encounter complainants who have come up against the 3 D’s – Deny, Delay and Defend. There are still far too many in the NHS employing this mind set when they harm someone. Some are that determined to avoid a complaint they even refuse to accept them from a family member.

Some will only accept a complaint once they can prove they are the next of kin, I’ve known families have to take in their marriage certificates or a Power of Attorney to register a complaint. If a loved one is still alive some insist only they can make the complaint. One patient I knew was 2 days into end of life care.

It is a cruel torture when you know that something has gone wrong but the organisation refuses to admit their mistakes and never says sorry. Many still think it is an admission of liability

but some patients/relatives often want nothing more than an apology.

Where can these families turn? Very often the Parliamentary Health Service Ombudsman (PHSO) doesn’t want to know. It is the next stage of the complaints process and really the only right of appeal. With new leadership, I am hoping in the future they will want to know. The Care Quality Commission doesn’t deal with individual complaints. These people are alone. They are cut adrift with no independent advice or counsel.

A recent study by the PHSO found older people are too frightened to complain and I must agree, I see this every day. Sometimes they will ask me if making a complaint will affect their next hospital stay and I can’t say it won’t.

Complaining is difficult. It is often at the worst time for people, riddled with grief and regret, who must then endure all manner of obfuscation and dishonesty – from missing case notes to stories being changed more often than the bed sheets. Too often it is just too much for people to subject themselves to. The first thing I ask when they contact me is, “How determined are you? Because you need to be.”

Once an organisation knows I’m involved families are treated differently. I’m not saying that they all get the answers but their calls get answered, they get replies to their letters and they are treated with much more respect. But this is no way to do business. Families shouldn’t be treated differently just because I’m involved.

I wish today I could tell you that the NHS is safe, I can’t. But what I can tell you is that there is a lot more people trying to make it safe, than there was in 2007, when I began my campaign to cure the NHS.

I’m encouraged by the enthusiasm and commitment to change amongst NHS staff. I think every single person and

organisation within the NHS has reflected on what needs to be done differently and many are doing things differently, which is what Sir Robert Francis asked from NHS staff. Getting the right leadership within the NHS is still a worry along with the right clinical leaders but we now, know and talk about this gap.

The NHS is a different landscape from 2007 but we still fail to learn from mistakes and get it right first time. The NHS does some wonderful things but when something goes wrong families want to know that they will get a fair and independent investigation and that lessons will be learnt. All too often they are not. Foundation trust status hasn’t helped. It created a system of competition instead of learning from each other. Although, I think the NHS has always struggled to learn from its mistakes. But the airline, nuclear and the construction industries were once the same so I remain hopeful.

Like the complaints process there’s nothing wrong with the process of investigation itself. I’m not going to single out one specific process as there are several that are worthy. No, the problem is the way it is carried out, often by whom it is carried out by and what happens afterwards. We’re back to behaviours.

We need the right people with the right skills, with much more emphasis on recruitment and training them to do such an important job. Equally important is leadership and how it can foster a culture where mistakes can be owned up to safely.

Mid Staffs produced a mountain of action plans, some very commendable. Sir Robert Francis singled one out during the public inquiry, it was the case of Gillian Astbury. It was an excellent investigation that examined the root cause of her death. Sadly the recommendations were never implemented, let alone audited. If implemented the loss of her life could have helped save many in Stafford and beyond.

After so many years of trying to help change the culture within the NHS, I’m convinced it needs help and that’s why I continue to support patients in an effort to simplify the system for all. The complicated nature of the procedures is the first barrier for most patients. The NHS is flooded with guidelines, regulations and initiatives, but it is action that is needed not another conference in a posh hotel where well-meaning but impotent people pat each other on the back and feel good about themselves whilst changing absolutely nothing.

I’m sorry if you think I have been too negative but I believe in getting the fundamentals right – communication, safe staffing levels, an appropriate skills mix and more patient involvement. Keep things simple and reward those who speak up.

I am heartened by the changes we have already achieved in the post-Francis NHS and I have touched on these major developments.

The CQC is a different body with a far greater degree of independence. We have different leadership and while I know they don’t get everything right they are a vast improvement on what came before. I remember the old CQC and its leadership with dread.

We know much more about our hospitals now, in 2007 I thought every hospital was safe. Today in England we know which hospitals are safer. Although I have recently moved to Wales and I am finding the transparency we have in England is only now beginning to emerge in Wales.

The NHS is much more transparent and open than it once was. In 2007 Health Ministers only wanted to hear good news. Some say we have always had a 7 day service but I know differently. Today we expect one.

My time is now spent trying to help people through the complaints system. I advocate for those unable to navigate

their way through the system of NHS complaints, the system that often drives people to despair. I work as an independent patient complaint consultant, offering the benefit of my experience to families who have nowhere else to turn.

Changing a culture is a daunting process but it will not happen unless individuals are prepared to stand up and fight for what is right. I have dedicated my life to helping those people and I am filled with hope that so many have the courage to stand up for what they believe in. Together we can create the health service we all deserve, but let’s get on and do it.

Julie Bailey CBE

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