This document provides an overview of major inquiries into failures in the UK National Health Service (NHS) since 1968. It discusses the purpose and process of inquiries, trends over time such as increasing scale and cost, common findings around organizational dysfunction and failures to learn from past mistakes, and debates around the impact and effectiveness of inquiries.

1. Learning from the past:
inquiries into major failures
in the NHS since 1968
Kieran Walshe
Professor of Health Policy and Management
Manchester Business School
kieran.walshe@mbs.ac.uk
kieran walshe@mbs ac uk

2. Overview
• Inquiries into major failures in care in the NHS – some
history and development
• Inquiries and investigations: purpose and process
• What we learn about healthcare organisations from
inquiries into major failures in care
• Conclusions/issues for d scuss o
Co c us o s/ ssues o discussion

3. History and development
• “Sans everything: a case to answer” and the whitewash
• Ely Hospital – the first modern inquiry in 1969
• The long-term care inquiries of the 1970s and 1980s – South
Ockenden, Farleigh, Napsbury, Normansfield…
• The big inquiries of the 1990s – Alder Hey, Ashworth, Ledward,
Bristol, Shipman
• The a a o C / C/CQC with statuto y po e s o investigation:
e arrival of CHI/HC/CQC t statutory powers of est gat o
Healthcare Commission did 14 investigations 2004-2007 incl
Northwick Park, Stoke Mandeville, Cornwall Partnership, etc
• More recent inquiries: Neale Ayling Kerr/Haslam
Neale, Ayling,
• Most recently: Mid-Staffordshire Hospital

4. Sans Everything: the inquiry
• “None of the allegations of cruelty or ill-treatment is
j
justified.. The charges of laziness and dishonesty are
g y
false and scandalous…”
• “The Matron took no action upon the complaints
because..
because being a kind and gentle person she did not
wish to needlessly upset her staff by seeming to
entertain unjust reflections upon their professional
competence
competence”
• “[The complainant] proved a most unreliable witness
whose judgement was manifestly unsound… she is a
j g y
rather solitary person with a somewhat simple mind..”

5. Ely Hospital: the inquiry
• Most allegations of mistreatment or cruelty found
p
proven – “Generally the situation at Ely has proved to
y y p
be sufficiently disturbing to make XY’s concern well
justified”
• “Lax and old fashioned standards of nursing
Lax old-fashioned nursing,
reminiscent in too many ways of the old era of
custodial care, have been accepted”
• “Virtual isolation… an inward looking community”;
“Serious overcrowding”; “Low standards of medical
care”; “The HMC and its officers must accept the
; p
principal responsibility for the shortcomings identified”

7. Ely Hospital, 1969
Hospital Mid-Staffordshire Hospital 2009
Hospital,
• “Lax and old fashioned standards of • “Taken individually, many of the
nursing, reminiscent of the old era of accounts I received indicated a
custodial care have been accepted.” standard of care which was totally
unacceptable. Together,
unacceptable Together they
demonstrate a systematic failure of
the provision of good care.”
• “An d l
“A unduly casual attitude t
l ttit d towardsd • “Incident
“I id t reporting systems were
ti t
sudden death [and] inadequate criticised by many staff... The Inquiry
systems for reporting incidents” found evidence that a number of
deaths had not been reported in this
system when they should have
been.”
• “All the male wards are seriously
overcrowded. The buildings are old
and ill-designed. The standards of
g • “More often there were inadequate
amenity fall far short of what would numbers of staff on duty to deal with
b f t ff d t t d l ith
nowadays be expected.... The staff the challenge of a population of
establishment [of one ward] is half elderly and confused patients.”
the minimum desirable...”

8. Ely Hospital, 1969
Hospital Mid-Staffordshire Hospital 2009
Hospital,
• “Members of the nursing staff who • “The few instances of reports by
were concerned about conditions whistleblowers of which the Inquiry
must have come to feel that it was was made aware suggest that the
almost more than their professional Trust has not offered the support and
pp
life was worth for them to voice any respect due to those brave enough to
feelings of concern.” take this step. The handling of these
cases is unlikely to encourage others
to come forward, and the responses
to the investigation of the concerns
raised have been ineffective.”
• “The Trust and its staff carried on
• “A structure of nursing administration much of its work in isolation from the
which has resulted in virtual wider NHS community It was not as
community.
isolation... in a close knit and inward open to outside influences and
looking community.” changes in practice as would have
been the case in other places.”
• “A lack of energ and sophistication
energy • “The consultant body largely
The
in medical care and record keeping... dissociated itself from management
The Physician Superintendent did too and often adopted a fatalistic
little to improve low standards of approach to management issues and
medical care.”
care. p
plans.”

9. Ely Hospital, 1969
Hospital Mid-Staffordshire Hospital 2009
Hospital,
• “The HMC and its officers must • “The Board’s collective failure
accept the principal responsibility was perhaps that of never fully
for the shortcomings identified: appreciating the risks to patients
an ineffective system of that were being taken on a day-
g y
administration...” to-day basis as a result of the
deficiencies that they were
seeking to tackle but had not yet
dealt with. There was a degree of
self satisfaction amplified by the
satisfaction,
achievement of FT status, and a
failure to detect or react to the
ever-strengthening wind of
concern that blew round the
Trust.”
• “The RHB and its officers have • “Concern is expressed that none
not accepted any responsibility of them from the PCT to the
for the inspection or supervision Healthcare Commission, or the
of standards at Ely and have local oversight and scrutiny
done little.. Nor has the hospital committees, detected anything
been subject to any other system wrong with t e Trust’s
o g t the ust s
of inspection...” performance until the HCC
investigation.”

10. More inquiries
• Allitt (Clothier inquiry)
• Ashworth (Blum Cooper inquiry)
• Bristol (Kennedy inquiry)
• Alder Hey (Redfern inquiry)
• Ledward (Ritchie inquiry)
ed a d ( tc e qu y)
• Shipman (Smith inquiry)
• Kerr/Haslam (Pleming inquiry)
• Neale (Matthews inquiry)
• Ayling (Pauffley inquiry)
• Mid-Staffordshire (F
Mid St ff d hi (Francis inquiry)
i i i )

11. International examples
• Untreated cervical cancer – Auckland, NZ
• Contaminated blood products – Canada
• Poor paediatric cardiac surgery – Winnipeg, Canada
• Deliberate harming of patients – Indiana USA
Indiana,
• Cytology screening errors – Gisbourne, NZ
• Poor obstetric and gynaecology service – Perth Australia
Perth,
• Poor general surgery – Virginia, USA
• Unnecessary cardiac surgery – California, USA

12. Trends and developments
• Increasing number, scale, scope and cost of inquiries
• Greater rigour, transparency and formality of process
rigour
• Growing overlaps between different inquiries by
different bodies – often successive inquiries with
q
different mandates and purposes
• New statutory role for Commission for Health
Improvement/Healthcare Commission/Care Quality
Commission in investigations

13. The purpose of inquiries
• Establishing the facts
• L
Learning f
i from events
t
• Catharsis or therapeutic exposure
• Public reassurance
• Accountability, blame and retribution
• Political considerations

14. Setting up inquiries
• Criteria for an inquiry
– Serious harm or loss to patients
– New or poorly understood issues of concern
– Widespread p
p public concern and loss of confidence
• Role of the “egregious event”
• Pressure from patients, the p
p public and the media

15. What kind of inquiry
• Internal NHS management inquiry
• H lth
Healthcare CCommission/Care Q lit C
i i /C Quality Commission
i i
investigation under s48 of Health and Social Care Act
2008
• External NHS private inquiry under s2 NHS Act 1977
• Statutory inquiry u de NHS Act 1977 o Tribunals o
Statuto y qu y under S ct 9 or bu a s of
Inquiry (Evidence) Act 1921 (now replaced by Inquiries
Act 2005)

16. Inquiry methods and issues
• Openness – meeting expectations and being effective
and efficient
• Fairness – to all stakeholders
• Rigour – validity and g
g y generalisability of findings, the
y g
inquiry as a case study
• Cost – from £20k for an internal inquiry to £15+ million
for a public inquiry
• Time – from weeks to 3+ years

17. Inquiry effects and impacts
• Effects through process and report publication
• The impact of the inquiry process itself and its use by
stakeholders/interest groups
• Content of the inquiry report and recommendations
q y p
and DH response
• Common findings and lessons
• Mechanisms for follow-up on wider implementation

18. Common findings
• Longstanding problems – exist for years or even
decades before being surfaced
• Well known but not tackled – high levels of tacit
knowledge did not lead to action
g
• Causes of immense harm to patients, healthcare
organisations, professionals
• Failures happen in dysfunctional organisations
• Similar major failures happen again and again and
again…

19. Common findings
• Failures centre on an individual – but organisational
pathology crucial
• Lack fundamental management systems, or they don’t
work
• Poor clinical and managerial leadership
• Inward looking, introverted a d c osed
a d oo g, t o e ted and closed
• Disempowered staff and patients

20. Common findings
• E d i secrecy and protectionism – the “ l b culture”
Endemic d i i h “club l ”
in healthcare
• Knowledge and responsibility fragmented – no one
g p y g
person or organisation has authority and incentive to
act
• Huge capacity for self-deception and post-hoc
self deception post hoc
rationalisation – disbelieve the data
• Informal mechanisms for dealing with failures – exit
without a fuss – move problems around
• Many major failures probably remain undisclosed –we
see the tip of the iceberg?

21. Conclusions and issues for discussion
• Inquiry costs and benefits – financial and other costs,
impact on those involved, new knowledge generated
involved generated,
other outputs/values
• Inquiry methodology – who chairs/leads, who
q y gy
investigates, risk of hindsight and other biases, how
generalisable are findings,
• Learning f
from inquiries – methods and mechanisms f
for
wider implementation, monitoring, follow-up