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.