In March last year, the Morecambe Bay Investigation report was published. The report looked at the care and treatment of mothers and babies at the maternity unit at Furness General Hospital between 2004 and 2013.
The findings of the report were stark; between 2004 and 2013, 11 babies and 1 mother died at the unit as a consequence of what the report described as ‘a lethal mix of failures’. One of the babies that died was my son, Joshua, in 2008.
The publication of the report marked an important moment personally; a formal recognition of what went wrong, and local and national recommendations to reduce the chance of anything like it happening again.
Since Joshua’s loss, I’ve changed my career from working as a project manager in the nuclear industry to working in the area of patient safety. This has been a deeply interesting and rewarding journey at a time of significant national focus on patient safety improvement. In 2013, I joined the Care Quality Commission as their National Advisor on Safety and recently I’ve been privileged to have been able to work and contribute to some exciting developments, including advising on the establishment of the new Healthcare Safety Investigation Branch.
Looking back at events at Morecambe Bay, a theme throughout the report was the failure to be open and honest about adverse incidents and a repeated failure to investigate and learn. The need for the NHS to improve the way it reports and responds to incidents is something I’ve written about in the past and is a topic I often speak about at patient safety conferences.
Attending and speaking at numerous patient safety conferences and events has also meant I’ve met many different people working in the area of patient safety. Over the years I’ve got to know Jonathan Hazan, formerly the Chief Executive and now Director at Datix. Jonathan is well known in the patient safety community in the UK and globally, being a strong advocate for improvements in reporting and patient safety culture. Last year I wrote a joint piece with Jonathan about the use of the phrase ‘I’ll Datix you’, which sadly, despite much progress, demonstrates that in the healthcare setting the purpose and value of a good incident reporting culture and process isn’t always understood.
Recently, Kaveh G Shojania, the Director of the Centre for Quality Improvement and Patient Safety at the University of Toronto said “Incident reporting is the single biggest waste of time in the last 15 years”.
Of course, as an end unto itself, the reporting and collection of information about incidents can never result in improvement or change. The 2015 NHS staff survey reported only 56% of staff felt confident that issues they did report would be addressed – it’s little wonder that where this is the case, staff might question the value of filling out a Datix report.
The Datix mission statement is ‘We help our customers protect patients from harm by creating opportunities to learn from things that go wrong.’
This statement reminds me of a poem that used to be on the notice boards at work in my former job in the nuclear industry and which brings home what reporting incidents, unsafe acts or conditions should really be about; ultimately making systems and processes safer and reducing the chance of avoidable harm and death. But this can only happen if the information is properly analysed, causal factors identified and changes made to prevent the same thing happening again.
Talking to Jonathan and the team here at Datix it’s clear to me the Datix mission statement is more than just a set of words. The central belief that Datix can help organisations to learn from mistakes to make healthcare safer is a core driver for everyone who works here.
For these reasons, I recently made the decision to join the Datix team at an exciting time for the organisation. I’m looking forward to contributing to new and exciting projects that I am sure will play an important role in further helping healthcare organisations learn from mistakes, continuously improve and ultimately save lives.