The Morecambe Bay Report
As shocking as the findings of the report are, the pressing question for those involved in the regulation of healthcare professions is where we go from here?
The report was of the view that the coincidence of failures that led to these tragic errors was very unlikely to be anything other than a rarity in other trusts. Nonetheless, it made a number of recommendations in respect of the wider NHS. A summary of some of these recommendations is set out below.
Duty of Candour
“We commend the introduction of the duty of candour for all NHS professionals. This should be extended to include the involvement of patients and relatives in the investigation of serious incidents, both to provide evidence that may otherwise be lacking and to receive personal feedback on the results.”
The GMC and NMC are due to publish this month their guidance on the statutory duty of candour. It is unclear whether the final guidance will reflect this recommendation from the Morecambe Bay report. The report has undoubtedly served to keep the duty of candour a high profile issue among the public and key stakeholders. The report noted, for example, that the events were only brought to light thanks to the efforts of “diligent and courageous families, who persistently refused to accept what they were being told.” One can expect that failures to comply with the statutory duty of candour will receive robust attention from the regulators given its public prominence and the political potency of patient safety.
Raising Concerns & Whistleblowing
A major issue to emerge from the Morecambe Bay report was the almost complete failure of healthcare professionals to raise concerns as to clinical failures and threats to patient safety. As with the duty of candour, this issue continues to garner headlines and political concern. The report recommends:
- The introduction of a clear national policy on whistleblowing;
- Professional regulatory bodies should clarify and reinforce the duty of professional staff to report concerns about clinical services, particularly where these relate to patient safety, and the mechanism to do so. Failure to report concerns should be regarded as a lapse from professional standards.
Professional regulatory bodies such as the GMC, GDC and NMC have already issued guidance on this topic. There is little within the Morecambe Bay report that will require substantial revision of these policies. It is likely, however, that continued focus on these topics will result in the regulators encouraging a particularly firm approach where there is a failure to report concerns, as distinct from the fact of errors themselves: “that mistakes were made should not itself be subject to criticism. What is inexcusable, however, is the repeated failure to examine adverse events properly, to be open and honest with those who suffered, and to learn so as to prevent recurrence.”
In response to the report the Health Secretary, Jeremy Hunt, said in a statement to Parliament that he would ask Sir Bruce Keogh, NHS England’s Medical Director, to look at whether professional codes need to be strengthened to ensure the right incentives are in place to allow healthcare professional to report concerns. Mr Hunt’s comment will strike a chord with those who represent healthcare professionals: “Within sensible professional boundaries, no one should lose their job for an honest mistake made with the best of intentions. The only cardinal offence is not to report that mistake openly so that the correct lessons can be learned.”
National Protocol For Inquests
The report highlighted that although some of the failings identified had sparked internal and external investigations, these investigations were either deficient or hampered by collusion and distortion of the truth. It also revealed a disturbing level of what it called “inappropriate distortion” in the preparation for an inquest which involved the circulation of “model answers”.
Those who advise and represent in relation to inquests would be wise to have regard to the relevant recommendations contained within the Morecambe Bay report. The report recommended that a national protocol should be drawn up setting out the duties of all trusts and their staff in relation to inquests, including:
- The avoidance of attempts to ‘fend off’ inquests
- A mandatory requirement not to coach staff or provide ‘model answers’
- The need to avoid collusion between staff on lines to take
- The inappropriateness of relying on coronial processes or expert opinions provided to coroners as a substitute for incident investigation
Although there has been little official response to these recommendations, they do serve to shine a spotlight on the preparation for, and conduct of, inquests.
The Morecambe Bay report added weight to the case for swift changes to the regulation of midwifery. The Parliamentary and Health Service Ombudsman Report 2013 and the King’s Fund review ‘Midwifery regulation in the United Kingdom’ have already highlighted the conflict of interest in midwifery supervision and regulation: “The dual role of a Supervisor, providing support but also a regulatory function, allows for an inherent conflict of interest.”
The Morecambe Bay report was clear that an urgent and effective reform of the system is required. In January 2015 the NMC Council accepted the recommendation that statutory supervision should no longer be part of its legal framework. The report looks to have sped up that development quite significantly. Jeremy Hunt, in a statement to Parliament, said: “The government will work closely with stakeholders to agree a more effective oversight arrangement and will legislate accordingly. I have asked for proposals on the new system by the end of July this year.”
The issues highlighted by the Morecambe Bay report are, sadly, not particularly novel. In fact, the whole affair presents a disturbing echo of the findings of Robert Francis QC regarding Mid-Staffordshire NHS Foundation Trust. As a consequence, the report is unlikely to usher in substantial and wholly new changes but rather add renewed vigour to encourage whistleblowing, openness and candour within the NHS and to reprimand obfuscation, denial and distortion.