Following the recommendations of the review conducted by Sir Norman Williams, the government has announced today that The GMC will lose the powers it used to appeal the MPTS decision in Dr Bawa Garba’s case.
The Williams Review also recommends:
1. Clearer understanding of where the bar is set for gross negligence manslaughter in healthcare so it only applies to cases of very poor performance, rather than honest mistakes.
2. The personal case notes of healthcare professionals may not be requested by regulators when investigating fitness to practice.
There are further details in the Department of Health Press Notice set out below.
HUNT ANNOUNCES NEW MEASURES TO IMPROVE PATIENT SAFETY AND PROTECT DOCTORS AND NURSES
- Stronger support to help doctors and nurses learn from mistakes
- Every single death to be scrutinised by medical examiners or coroners
- GMC no longer able to appeal Medical Practitioners’ Tribunal rulings
- New programme offering doctors confidential data on their results and how they compare nationally to support learning and improvement
Healthcare professionals including doctors and nurses will be supported to examine and learn from ordinary mistakes without fear it will be used against them, following the case of Dr Bawa-Garba earlier this year and the subsequent review into gross negligence manslaughter in healthcare by Professor Sir Norman Williams.
Alongside this, patients and their families will see better scrutiny of deaths in the NHS as a system of medical examiners is rolled out to look at all patient deaths that aren’t referred to a coroner.
These changes will mean bereaved families will get more information about the circumstances of their loved ones’ death and much more data will be shared across the NHS to help prevent avoidable deaths and improve public health.
Health and Social Care Secretary Jeremy Hunt said:
“When something goes tragically wrong in healthcare, the best apology to grieving families is to guarantee that no-one will experience that same heartache again. I was deeply concerned about the unintended chilling effect on clinicians’ ability to learn from mistakes following recent court rulings, and the actions from this authoritative review will help us promise them that the NHS will support them to learn rather than seek to blame.
“Combined with our medical examiners, learning from deaths and clinical improvement programme, these measures are the next phase in our patient safety reforms, supporting the NHS to seize every opportunity to learn vital lessons when tragic errors occur.”
The Williams review followed concerns among healthcare professionals that errors could result in prosecution for gross negligence manslaughter, even in the face of broader organisation and system failings.
Led by eminent surgeon Professor Sir Norman Williams, the review recommends vital changes for the system regulating healthcare professionals so they are supported to reflect on their practice when things go wrong, including:
1. The removal of the General Medical Council’s power to appeal the outcomes of their tribunals. This change would mean decisions by the Medical Practitioners’ Tribunal can only be appealed by the Professional Standards Authority.
2. Healthcare professionals’ personal case notes – known as reflective material – will not be able to be requested by regulators when investigating fitness to practice. This change will help ensure healthcare professionals aren’t afraid to use their notes for open, honest reflection and how they could improve patient care.
3. Developing a clearer understanding of where the bar is set for gross negligence manslaughter in healthcare, so that healthcare professionals are reassured this type of criminal sanction only applies to cases of very poor performance, rather than honest mistakes.
4. Improve the processes involved in healthcare professionals providing expert opinion in criminal and regulatory cases.
Improving patient safety has been a key feature of Jeremy Hunt’s tenure as the country’s longest serving health secretary, during which the NHS has twice been ranked as the safest healthcare system in the world.
Medical examiners will be experienced doctors, who will scrutinise all deaths. If something requires further investigation, including circumstances that seem unnatural or unexplained, then they will be able to refer the case to a coroner for other investigations, or work with local health and care services if issues need to be improved.
Pilot sites trialling a system of medical examiners in Sheffield and Gloucester have shown that through the additional scrutiny, there is better engagement with the bereaved and a more effective process for working with coroners.
Building on this success, the Health and Social Care Secretary has also announced:
1. GPs and ambulance trusts will be the next focus for reviewing deaths to help understand and tackle patient safety issues. This follows the publication last year of the first national Learning from Deaths policy, which requires NHS trusts to publish numbers of deaths thought to be due to problems in care and evidence of what they have learned and improved to prevent such deaths in future. By looking at how to extend this to GPs and ambulance trusts, more parts of the NHS will be made safer by generating learning and enabling local health organisations to learn from one another.
2. A new programme will offer NHS consultants confidential data on their own clinical results and how they compare nationally to support them to learn and improve. The National Clinical Improvement Programme (NCIP) – being developed by the Getting It Right First Time (GIRFT) team with input from Royal Colleges and Specialty Associations – will give consultants in England access to their clinical results via an online portal. This will initially be for consultants in general surgery, paediatric surgery and urology.
Professor Sir Norman Williams added:
“This Review has provided an opportunity to understand the impact of investigations and prosecutions into gross negligence manslaughter in healthcare. The panel heard from a wide array of individuals and organisations, including bereaved families, healthcare professionals and their professional bodies, regulatory bodies, lawyers, and investigatory and prosecutorial authorities. We are very grateful to all who shared their experience and knowledge with us.
“The recommendations support a just and learning culture in healthcare, leading to improved patient safety. A clearer understanding of the bar for gross negligence manslaughter in law should lead to fewer criminal investigations which are limited to just those rare cases where an individual’s performance is so “truly exceptionally bad” that it requires a criminal sanction. This clarity together with an understanding by the investigatory authorities as to the complexity of modern healthcare in which the individual operates should help to dispel the real fear felt by healthcare professionals who are concerned that in the well-intentioned discharge of their duty they may be subject to criminal or regulatory processes.
“These recommendations will, we hope, reassure the families and loved ones of the bereaved that lessons have been learned from their tragic experiences. Where things go wrong and a patient dies, the family and loved ones will be treated fairly, with respect and will receive honest explanations when things have gone wrong, as well as seeing effective action by the police, courts and regulators when appropriate.”