Sepsis and Why the NHS Needs a No-Blame Culture

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paul-sankey-enable-lawNot only are failures in recognising and managing sepsis a shortcoming in our health service but the problems they cause are among the most serious possible. The systems are there for staff to use and it is difficult to understand why the management of sepsis is not better.

Last year the father of Sam Morrish, a toddler from Newton Abbott who died from sepsis, highlighted the need for a more open NHS culture if lessons are to be learned from avoidable errors.

3 year old Sam tragically died 36 hours after falling ill. His GPs, the on call service, NHS 111 and Torbay Hospital all failed to recognise and treat the condition in time.

Sepsis is a very serious condition and needs urgent treatment. The body’s immune system reacts to infection in a way which can cause harm to vital organs. The aim of treatment is both to support breathing and blood circulation and to treat the underlying infection. According to The UK Sepsis Trust more than 150,000 people develop sepsis in the UK each year and 44,000 die. Among the survivors many end up seriously disabled, some suffering amputations.

Sam’s father was dissatisfied with the response to his complaint. He told a parliamentary select committee that investigations were inadequate because staff were fearful to speak out. He called for a no-blame culture and a system similar to the aviation industry where staff can be open and honest about mistakes in the interests of learning from them.

He is right both in saying that the airline industry and the NHS have been at opposite ends of the spectrum when it comes to learning from mistakes. Fewer people died from air accidents in 2012 than in any year since the 1940s when there were hardly any commercial flights. The reason is that each air accident is carefully analysed and data retrieved from the ‘black box’ and other sources. The results of investigations are widely shared so that lessons are learned and mistakes are not repeated. The aviation industry now has a culture where operators, pilots and air traffic controllers volunteer information about errors. The major change occurred when the aviation industry realised that without knowing what went wrong, it could not learn from mistakes or prevent accidents.

Unfortunately the NHS has found it difficult to adopt the same approach. Although doctors have professional duties to tell patients and managers when things go wrong, managers have not. And the health industry’s culture has made it difficult for staff to be open about mistakes. More recently the government has introduced a ‘duty of candour’. There is however little evidence of any real difference on the ground.

Mr Morrish rightly thinks there is too much blame in the system. “There needs to be a move to nurturing and compassion to staff so that they can in turn deliver that to patients. They need to know that if they have made a mistake that they can speak freely.”

The need for a more open culture is particularly important when it comes to sepsis. Sepsis is something of a Cinderella condition. Despite it causing more deaths each year than bowel, breast and prostate cancer combined (according to The UK Sepsis Trust), it is a condition which is often diagnosed too late. Sadly the results can be catastrophic as they were for Sam Morrish and his family.

What happened to Sam was tragic. It would have been easy for his father focus on blame but he is absolutely right that we need a no-blame culture if any good is to come from Sam’s sad story.

Enable Law supports The UK Sepsis Trust in seeking to increase awareness about sepsis and to support families affected by it.
An inquiry held in Westminster was set up to examine the failures into the initial investigation into the case, and Mr Morrish told the committee that so far, the pace of change has been too slow.

He showed the inquiry an information leaflet made in Sam’s name to help parents and healthcare staff identify sepsis.

But despite promises, the leaflet has not been rolled out across the UK and could undergo a further two years of evaluation before any further progress is made – eight years since Sam’s death.

He told the committee: “We have been told for five years that lessons have been learned but those lessons are only just beginning. The actions that need to follow have barely started. It should not take this long and I don’t know why people have so much tolerance of it taking this long.”

The government is obliged to respond to the committee findings.

Mr Morrish was a witness to the inquiry alongside Steve Shorrock, European Safety Culture, Programme Leader, Prof. Sir Mike Richards, Chief Inspector of Hospitals, Care Quality Commission, Keith Conradi, Head of the new Healthcare Safety Investigation Branch and Helen Buckingham, Executive Director of Corporate Affairs, Care Quality Commission.

Julie Mellor, the Parliamentary Health Ombudsman who completed the two reports into the case said after the hearing that still too many NHS investigations into avoidable deaths are inadequate.

She said: “Sadly the experience of the Morrish family is not unique. We see too many local NHS investigations into avoidable deaths that are not fit for purpose.

‘We have recommended that people at the top of the NHS consider how they can create an environment in which leaders and staff in every NHS organisation feel confident and have the competence to find out why something went wrong and to learn from it.”

The ombudsman’s report in 2014 revealed that a catalogue of errors led to Sam’s death. He was failed by all the NHS medics who saw him 36 hours before he died of severe blood poisoning. Despite clear signs of developing illness, GPs at Cricketfield Surgery in Newton Abbot, the Devon Doctors on call service, NHS 111 and Torbay Hospital all failed to treat him until too late.

Sam’s parents were directed to a local treatment centre by an unqualified out-of-hours call handler, when he should have been gone immediately to A&E. When he was eventually rushed to Torbay Hospital, it took three hours for staff to give him antibiotics, by which point a bacterial infection had already taken hold. He died of septic shock the following day, two days before Christmas on December 23, 2010.