The sixth report of the 2014-15 session of the House of
Commons Public Administration Select Committee concerns investigating clinical
incidents in the NHS.
It takes a refreshing approach to human error and has
obvious implications for how human error in child protection, in the NHS and
elsewhere, should be approached. The report has two important themes both of which
I heartily endorse: learning from approaches to safety in civil aviation and
fostering an open and just reporting culture.
The committee endorsed the model of the Air Accident
Investigation Branch (AAIB) as being a most appropriate way to learn from human
error in the NHS. That’s something that I feel very pleased about because I
have on several occasions since 2010 said something very similar about what
should happen in child protection.
Members of the Committee heard from Keith Conradi, the AAIB’s Chief
Inspector of Air Accidents. He told the Committee that:
“People […] have
learned that, if they actually report these things, when they come to our
attention, they are dealt with in a very much no-blame environment. We go to
great lengths to ensure that our reports and our investigations do not carry
any blame or liability.” (Para. 83)
The Association of
Surgeons of Great Britain and Ireland told the committee that: “… many of the
principles incorporated by aviation could be readily applied to medical
practice and would bring about change in the long term.” (Para. 86)
The Secretary of State for Health told the Committee that
the “processes that we are trying to create have been modelled on those in the
airline industry, which are designed to make it incredibly easy for pilots to
speak up”. (Para. 86)
The committee drew the following conclusion:
“An open
and just culture is one in which incidents and failures are openly and honestly
discussed by staff, patients and families, creating an environment where the
causes of serious events can be established and lessons can be widely learned.” (Para. 86)
If this is the right approach for the NHS, then it must also
be the right approach for children’s services, the police, education and other
parts of the child protection system. It is about time that ministers in the
Department for Education, which has responsibility for child protection policy
in England, took notice of how informed opinion in the NHS is embracing an
aviation inspired approach to safety.
