The Doctors’ Association UK is pleased that the report agrees with our written submission that the provision for the HSSIB to accredit NHS trusts to do their own ‘safe space’ investigations is an enormous conflict of interest. We are therefore delighted that the report has recommended that the entirety of part 3 of the draft Bill, relating to Trust accreditation, be dropped.

The Doctors’ Association UK is also pleased that the report agrees the value of the HSIB as an independent body, bringing medicine in line with the rail and aviation industries. ‘Safe space’ investigations will allow staff to speak freely and determine what went wrong to prevent similar mistakes happening again. If ‘safe space’ investigations are to carry the confidence of the public, the independence of the HSIB must be assured.

The Doctors’ Association UK’s central campaign is entitled “Learn Not Blame”, and seeks to engender a national conversation about the need for a just culture in the NHS. We are campaigning for a step change in the NHS so that honest error is used to drive learning and change for a safer, better NHS, rather than being a focus for individual blame. The creation of a truly independent body is a welcome step towards this.

‘For those of us observing it’s still hard to believe that we have got to the stage where an otherwise dedicated and hard working doctor has been criminally prosecuted and taken to court by the GMC for what were essentially honest mistakes [made when] working under pressure,’ she said.

Dr Bawa-Garba is appealing a decision made in January by two High Court judges that she should be erased from the medical register rather than receive the year’s suspension that had previously been imposed by the Medical Practitioners Tribunal Service (MPTS).

‘Systemic failings’

Their ruling followed a successful appeal by the GMC, which argued that suspension was ‘not sufficient’ to protect the public or maintain public confidence in the medical profession.

On Wednesday, the opening day of the appeal, Dr Bawa-Garba’s counsel James Laddie QC said there was particular concern in the medical profession over the court’s decision to disregard ‘systemic failings’ which contributed to the environment in which Dr Bawa-Garba came to make the mistakes leading to the death of six-year-old Jack Adcock in 2011.

Dr Batt-Rawden, who sat in court during the appeal’s opening yesterday, said: ‘Particularly concerning to all of us has been the GMC’s line of argument. To an observer, it seems the crux of their argument is that system failures were not relevant in Hadiza’s case, and should not have been taken into account by the MPTS when determining her level of culpability and her sanction.

‘This has huge ramifications for the medical profession and for patient safety. We are all working in an immensely pressured system, with widespread staffing issues and rota gaps. Hadiza’s story of doing the jobs of several doctors at once, across multiple wards and multiple floors, with a failing IT system, in the absence of senior colleagues or indeed a consultant is sadly increasingly common.

‘Before this case I don’t think any doctors thought that mistakes made whilst simply trying their best under such pressured circumstances would ever lead to a criminal conviction, or erasure from the register. Now, all of us are feeling vulnerable.’

In written argument before the court, Ivan Hare QC for the GMC said the appeal should be dismissed because the High Court was correct to decide that the MPTS failed to apply the relevant rule of the GMC (Fitness to Practise) Rules Order of Council 2004 and undermined the rationale for making criminal convictions conclusive evidence of the offence committed in disciplinary cases.

In response to Dr Bawa-Garba’s case, The Doctors’ Association UK has launched a new campaign ‘Learn not Blame’.

‘We must move away from a culture of blame and fear, to one of learning,’ Dr Batt-Rawden said. ‘We repeatedly fail to learn from scandals such as Mid-Staffs and Gosport and the NHS urgently needs a safe space to enable staff to speak up about patient safety issues.’

She added that there are ‘no winners’ in a culture which seeks to blame one individual for medical error whilst failing to address wider system failures.

‘Our ongoing campaign seeks to empower doctors to be part of a transformational change process working towards a shift from a culture of blame, to one of learning.’

She concluded: ‘An unsuccessful appeal today would do further damage to a profession whose morale is already at rock bottom, and signals a further move away from the open, transparent NHS that we all want to see.’

We need a culture of learning, not of blame and persecution. We need a culture of compassion and care for all who are served by it and all who work in it. A culture where mistakes and harm are prevented by openness, listening and learning. And where mistakes and harm do happen, change, not blame, is the outcome. A just culture. This is the only way we will see a real improvement in patient safety.

This campaign has been born out of a growing awareness amongst clinicians of how a toxic mix of defensiveness and concern for reputation management above all else can lead to blame-seeking culture. This is bad for doctors and worse still for patient safety.

Most patients and families, when things go wrong in healthcare, just want to know honestly what happened and make sure that the same thing never happens to anyone else. But many people face a brick wall when seeking answers from NHS organisations, and get pushed into an adversarial complaints procedure, or even litigation.

Equally, staff who raise concerns often find themselves the subject of counter-accusations, victimisation and blame, instead of having their concerns acted upon. Staff are forced into a formal whistleblowing procedure, where the ensuing legal action may bankrupt them and ruin their careers.

This campaign aims to bring doctors together to say – enough. This has to stop.

The campaign will encourage individuals to commit to action within their own sphere of influence, and join together as a movement to put pressure on NHS leadership to mirror that change and commit at a Trust or Health Board level to an open, learning and just culture.

Look out for more details coming soon, and how YOU can be the change.

#LearnNotBlame