How can the NHS build a culture where errors related to GBS are effectively raised?

If a baby develops a group B strep infection there may be questions about the care the mother and baby have received, especially if there are feelings that the infection could have been avoided. Sometimes things go wrong and nothing could have been done to prevent it, though in certain circumstances that is not the case.

The Ockenden report into the ‘maternity care scandal’ at Shrewsbury and Telford NHS Trust has been in the news again lately due to a leak of the interim report. Several of the families identified by the report had almost identical experiences of group B Strep infection.

In response to the leaked report, Jane Plumb MBE, the Chief Executive of Group B strep Support said:

“Given several of the families identified in the Ockenden report had almost identical experiences of group B strep infection, I am incredibly sad that the leaked report has uncovered alleged widespread failings in care and clinical malpractice. Parents like Kayleigh Griffiths, Charlotte Cheshire and Hayley Matthews all had children who were severely ill or even died as a result of group B strep infection. The leaked report highlights a missed opportunity to improve group B strep prevention by learning from mistakes. Although we don’t know the full details, we do know that when clinical guidelines are followed properly, many tragedies can be avoided.”

Reading about this has made me consider why the same failings can seem to occur time and time again? Why are clinicians not learning from these mistakes? Were concerns raised? I wondered whether there is in fact, more to it.

My reading took me to a recent study published in the journal of the Royal Society of Medicine 2019. Vol. 112(10) 428-437 entitled ‘Understanding the factors influencing doctors’ intentions to report patient safety concerns: a qualitative study’.

It is critical that patient safety is improved and doctors’ attitudes towards raising concerns is something that has been looked at with a view to improving the safety of patients.

This study looked at the thought processes and attitudes of doctors when considering raising concerns. Literature like the Okenden report highlights how critical it is that patient safety is improved so understanding the reasons behind whether doctors raise concerns or not is imperative.

The study showed that raising a concern in practice was not as straightforward as the regulator guidance suggested. It highlighted the following factors that facilitate and hinder raising a concern:

Attitudes towards raising a concern

Whilst there is regulator guidance as to when concerns should be raised, the study found that the decision to raise a concern was mainly triggered by the doctors’ own ethical code rather than regulator guidance.

Fear of negative consequences for themselves and others

A number of doctors interviewed as part of the study had a fear of there being negative consequences for themselves if they raised a concern, such as being labelled as difficult and becoming isolated from colleagues (who were also friends) as a result.

There was also a real fear of negative consequences for the doctor who is the subject of any concern. The study showed that the participants had a great deal of empathy to the personal situations of other doctors and also said that, when considering whether to raise a concern, they took into account the likely damaging consequences for the other doctor’s career, financial difficulties that would ensue, and other social circumstances.

There was an expectation that the path ahead would be challenging and unsupported. The lengthy timescales under which a doctor would be subject to investigation was a further negative. They were conscious of the stressful impact of an investigation on doctors and how the slow process may intensify this.

Organisational pressures

The study highlighted that the culture of the organisation was considered to be crucial in determining whether a risk to patient safety was raised. Some participants expressed that, while colleagues would agree in principle that raising a safety concern was appropriate, the reality of raising a concern in practice was frequently met with disapproval from  management, other health professionals and administrators.

The potential impact on resources, targets and workload were also felt to be a further barrier.

There was a consensus that there would be greater scrutiny for a person who reports an incident, whereas someone who did not report incidents would remain under the radar.

One of the participants stated:

“In appraisal you will pick up the person who is spewing out lots of incident reports and is involved with lots of clinical incidents, but just as dangerous actually, is perhaps the person who is not doing anything, not reacting to what they are seeing”.

Negative treatment of whistleblowers

Blowing the whistle in the NHS is meant to be easy. Medical bodies such as the Department of Health and Social Care, the General Medical Council (GMC) and individual hospital trusts all encourage this practice on paper. In reality however there is a huge fear amongst doctors of how they will be treated if they do blow the whistle.

A number of doctors in the aforementioned study highlighted the case of Chris Day. Chris Day was a junior intensive care doctor who raised numerous concerns about understaffing and safety at the intensive care unit of Queen Elizabeth Hospital in Woolwich. He made a protected disclosure to hospital management and to Health Education England which oversees junior doctors training and career development – about the understaffing. He argued that, rather than being believed, he became the victim of a pernicious effort to discredit him and the issues he had raised. A number of counter allegations were made against him and his Health Education England training number was deleted, effectively forcing him out of his career.

Chris Day went to an employment tribunal on the basis that his initial concerns hadn’t been taken seriously and that he was suffering detriment including loss of earnings as a result of having raised them. During the initial hearing Health Education England successfully argued that they didn’t have a duty to protect whistleblowing junior doctors suffering any kind of detriment because it wasn’t legally their employer.

The case evoked fear into junior and senior doctors who worried that they themselves would not be protected for whistleblowing and this uncertainty caused ambivalence towards raising concerns.

Whistleblowers were also not perceived to be publicly praised for their actions, resulting in a lack of positive stories and role models for raising concerns. Consequently raising a concern was viewed as negative.

Doctors often felt disempowered to raise a concern if the person who was the subject of the concern had greater authority

Due to perceived negative repercussions for the doctor raising the concern, having the support and approval of colleagues was an important factor in the decision to take action.

Junior doctors highlighted the power position of their supervisor and the potential conflict of interest if a concern is raised about an assessor. Raising a concern against someone with more power was considered more challenging.

Disempowered

A number of participants in the study stated that due to there having been a lack of action from raising safety concerns in the past, they stopped raising them. They did not believe that their actions could result in an improvement to patient safety and so thought there was no point.

What can be done to make it easier for doctors to raise concerns?

The study set out a number of improvements that could be made, based on the information it gleaned in respect of:

1 - Individual barriers to raising concerns?

Reducing practical barriers such as workload, speeding up the investigation process and providing support for doctors under investigation, and providing doctors with feedback on the concerns raised.

2 - Interpersonal barriers to raising concerns?

Support at a team level to proactively facilitate and protect interpersonal relationships with colleagues, particularly for those who wish to raise a concern regarding those in a powerful position.

3 - Organisational barriers to raising concerns?

Addressing organisational culture including processes for incident reporting and concerns being followed, addressing the negative treatment of whistle-blowers and providing good news stories which would encourage raising concerns.

There are ongoing efforts to address some of these barriers since the first publication of the Francis Report into the failings of care at Mid Staffordshire NHS Trust, and more recently the Freedom to SpeakUp review into whistleblowing which highlighted that many remain fearful of raising a concern.

Reforms designed to protect whistle-blowers include the introduction of Freedom to Speak Up guidelines, as well as a dedicated person in each NHS Trust whose role is to lead culture change and to whom staff can speak to confidentially. There has also been a reduction in the timescales for doctors undergoing fitness to practice investigations. Finally, the GMC also provides helplines for doctors who feel unable to raise concerns at a local level.

These reforms indicate that progress is being made. However, there is still reluctance to raise concerns and this poses a continued risk to patient safety. There remains a substantial amount of work to do in fostering a culture where doctors feel able and supported to raise a safety concern without fear of negative repercussion. If significant improvements can be made in this regard, the impact on Group B strep incidents can only be positive.