Learning from failings in healthcare: a challenge for all healthcare systems

Might Mid Staffs be a turning point? The most important single change in the NHS in response to this report would be for it to become more than ever before a system devoted to continual learning and improvement of patient care, top to bottom, end to end. 1 Reactions to significant and public failures in healthcare in the UK, and no doubt elsewhere in the world, trigger forensic inquiries. The aim, after finding out what went wrong, is to draw out lessons with the aim of ‘ it’ never happening again. Each inquiry, whether small and internal or large and statutory, publishes a report with recommendations. These reports make difficult reading for anyone working in healthcare. For although the context and clinical details are never quite the same, they point to similar and familiar failures. The latest public failing in the UK has triggered not one but two inquiries and three reports: a report followed each inquiry with a third from an expert group, chaired by Professor Don Berwick, charged with taking the lessons from this latest failing and specifying what changes are needed to make the National Health Service (NHS) a safer health system. Will this third report, written to, and for, everyone in the NHS, make a lasting difference? The context for the Berwick report is the care provided at Mid Staffordshire Trust, a district hospital in the English West Midlands. Concerns about standards and the safety of care, and a higher than expected death rate, alerted the regulator, the Health Care Commission, which in 2009 investigated this hospital and published a report very critical of standards of care. There followed reports by the Department of Health and, later in 2009, the Secretary of State for Health commissioned an independent inquiry chaired by Robert Francis QC, which reported …