Regulars will know Prof Brian Edwards has followed every step of the Infected Blood Inquiry for us.
It is only right that I leave it with him to sum-up the enormity of the findings and their ramifications.
Here is his report…
A Scandal Exposed.
I struggled through the crowds and television crews to get into Westminster Hall to hear Sir Brian Langstaff present his report on Infected Blood.
The hall was packed full of patients, parents, and friends of families whose lives had been harmed and changed.
The mood was mixed.
For almost everybody, there was relief that the story of their suffering was at last being told but this was mixed with sadness and anger.
Langstaff was greeted with loud applause as he arrived on the stage and at the end of his presentation. It was not his report, he claimed, but the story of all those present and those watching at home.
The seven volumes of his report sat in front of him.
“The calamitous events that had hurt or killed so many was not an accident” he said.
Three thousand patients need not have died, and many others need not have gone through the trauma of their illness and experienced a sharply diminished quality of life.
For many the agony continues.
Clinicians, civil servants, ministers, and the NHS had let them down…badly.
For many years they had been in denial about the risks and held to the line that;
“…there was no proof that blood products could be linked to Aids or Hepatitis”.
Ministers argued that patients had received the best treatment available in the light of the clinical knowledge available at the time.
Not true, claimed Sir David.
Risk could never be avoided but it could be reduced. The assertion that the screening of donors could not have been improved until the science was clear was simply untrue.
Parents and children were not asked for informed consent before being given varying doses of Factor 8. Some clinical research involving children had been unethical.
A Ministerial decision [Dr David Owen] to make the UK self-sufficient in blood and blood products had never been properly implemented by the DH.
An alternative treatment to factor 8, cryoprecipitate, which was not as convenient or as novel as factor 8, but it was dramatically safer, could have been made more widely available. Sheffield Children’s Hospital, which opted for the cautionary approach, had almost no deaths whilst Alder Hay in Liverpool had a great many.
Doctor/Patient communications was often poor as was record keeping. Some records had been deliberately destroyed to hide the truth.
Professor Arthur Bloom chair of the Haemophilia Centre Director’s group comes in for major criticism although he died some years ago. He reassured civil servants and the Hemophilia Society that there was no need to ban imported blood products. In his view the benefits far outweighed the risk.
It seems that the headline in the Daily Mail about the dangers of importing blood from the US emanated from one of Bloom’s colleagues.
An early whistleblower who was ignored.
It was a terrible story to hear but often met with applause as its awfulness was laid bare, at last the truth!
Langstaff makes many recommendations for the future.
Some sensible, practical, and easily implementable, others hopelessly inspirational with little chance of achievement without radical and fundamental change.
Sir Brian may be a great lawyer and seeker of the truth, but he has little, if any, expertise in changing large, complicated organisations.
The first and in his view the most important of his recommendations was that patients and families be quickly compensated for their loss. [Over £10 billion and counting]
This should have been done years ago. It was a sensible and clever move to ask Sir Robert Francis to lead the agency to be created to handle payments.
• The NHS to move decisively into a mandatory patient safety culture.
• No blame for reporting adverse events or near misses. Blame for not reporting.
• NHS Leaders and civil servants to be subject to a Statutory Duty of Candour.
• NHS and civil service to stop being institutionally defensive. [Even if it means ignoring legal advice designed to limit cost or damage to reputation!]
• Patients should be more involved in the management of health care.
There are many more which will be explored in later reports.
One or two initial reflections of mine.
Infected blood was an international problem. What distinguishes the UK is the way it was handled by both the NHS and government. It was to use the words of the Prime Minister “shameful.”
Amanda Pritchard (NHSE CE O) needs to have a really serious conversation with NHS managers and leaders of the health professions about how to react and what to do next.
A culture of patient safety will be hard to impose, particularly with the current pressures on the NHS and present difficult political choices.
Getting improved productivity safely is no easy task.
No more dangerous overcrowded wards even if this lengthens waiting lists?
No more extended hours and extra weekend work for tired staff. [Directly contradicting Labour’s Plans].
No more poorly inducted locums.
Decisively improved clinician/patient communication [A matter of culture as well as training].
Vastly improved patient safety information systems with real time alert signals for adverse events.
A “no blame” culture where medics, including juniors, feel safe to report unsafe clinical practices by their colleagues or perceived dangers for patients.
No more Treasury imposed targets if they generate increased risk. The DH should learn to say NO.
Making non-reporting of adverse events a disciplinary matter is not going to be easy.
This conversation with managers and the health professions is primarily a matter for Ms. Pritchard as the leader of the NHS and her team. Politicians and civil servants can support her, but they have neither the skills nor experience to manage this level of change.
All organisations including the government have an inbuilt defensiveness supported by teams of lawyers who see their role as limiting cost or reputational damage.
Ministers were warned by civil servants that if they approved compensation payments without proof of negligence it would be disastrous for the NHS.
Given the thousands of harmed patients waiting for the outcome of this Inquiry they may be right!
Patients harmed with implanted mesh is just one example. Turning this ship round will not be easy.
This cannot go on. We now need to think seriously about no fault compensation but interestingly Sir David did not. But he is a lawyer!
We need clear, consistent, and firm guidelines as to what a health professional should do if they think a colleague is unsafe or incompetent. A challenge for the regulatory bodies, the Royal Colleges, and medical directors who for medicine are often the first port of call.
Those doctors caught up in this story thought that they were doing their best for their patients. They did not set out to harm them. A few were very successful, skilled and caring.
Others ignored warning signs, did not share the risk analysis with their patients and were unethical in their research practices. “Doctor always knows best” was the phrase used by Langstaff.
However, if people’s faith in their doctors is seriously damaged, we will have an even more serious problem on our hands.
We need to reassure our clinical community of the respect we hold them in and get them fully engaged in the creation of a safer NHS.
In some cases, they might take the lead.
Was this a learning Inquiry or a search for blame?
Many families want revenge as well as compensation. Many of those judged to have been at fault had died or retired.
Dealing with these families anger and distress is another major challenge for the NHS.
Those that have survived need the finest and most sensitive care possible.
News and Comment from Roy Lilley
Contact Roy – please use this e-address roy.lilley@nhsmanagers.net
Reproduced at thetrainingnet.com by kind permission of Roy Lilley.
