Culture change is needed across NHS to prevent cover-ups – blood inquiry report

Sir Brian Langstaff said it was a ‘sad fact’ that most inquiries into the NHS ended with a recommendation that the culture should change.

Sir Brian Langstaff has called for a change to NHS culture as part of his report into infected blood
Sir Brian Langstaff has called for a change to NHS culture as part of his report into infected blood (Infected Blood Inquiry/PA)

A “culture change” is needed across the NHS to prevent cover-ups and to acknowledge mistakes, with individual managers held personally accountable if they fail to take action, the Infected Blood Inquiry has recommended.

Following the publication of his report into the treatment disaster, Sir Brian Langstaff said his main point remained that a compensation scheme was needed now for all those affected by the scandal.

But, he said repeated inquiries and reports have highlighted how the culture of the NHS needs to shift to one where mistakes are recognised and there is openness and transparency.

He said there was a need for culture change “such that safety is embedded as a first principle, and is regarded as an essential measure of the quality of care”.

He added: “Though performance, efficiency, and expense are all important, it should be the safety of care in any health institution that is the aspect in which all its staff take particular pride.”

In his address to attendees on Monday, Sir Brian said that those responsible in the infected blood disaster should be blamed for keeping silent, as he listed his recommendations.

Where an individual is responsible for something going wrong “they should certainly be blamed if they keep silent” and be obliged to report “near misses” as well as actual wrongs, the inquiry chairman said.

Leaders in healthcare should be made subject to a statutory duty of candour, the regulatory landscape for patient safety should be “decluttered”, and the NHS should establish a safety management system, he also said.

In the report, Sir Brian said it was a “sad fact” that very few inquiries into aspects of the health service have ended without recognition that the culture needed to change.

“Over the past 50 to 60 years there have been several inquiries, of different types – but nearly all have had some such recommendation,” he said.

Sir Brian said it was necessary for “individuals in leadership positions” to be required by law to “record, consider and respond to any concern about the healthcare being provided, or the way it is being provided, where there reasonably appears to be a risk that a patient might suffer harm, or has done so.”

Sir Brian Langstaff, left, speaks to infected blood victims and campaigners outside Central Hall in Westminster, London
Sir Brian Langstaff, left, speaks to infected blood victims and campaigners outside Central Hall in Westminster, London (Jeff Moore/PA)

He added: “Any person in authority to whom such a report is made should be personally accountable for a failure to consider it adequately.”

The inquiry chairman argued that the “culture of defensiveness, lack of openness, failure to be forthcoming, and being dismissive of concerns” could be tackled by “making leaders accountable for how the culture operates in their part of the system, and for the way in which it involves patients”.

A review should also be carried out into the numerous regulatory bodies covering the NHS and how they work together, he said.

A “duty of candour” already exists in the NHS compelling health service workers to be open and honest with patients about mistakes.

Sir Brian said this is being reviewed in England to see how effective it is in practice, and he called for a similar exercise in Scotland and Wales, as well as establishing a duty of candour in Northern Ireland.

The report further called for an end to the “defensive culture in the civil service and government”, saying the Government should consider if it is still sufficient to “rely on the current non-statutory duties in the civil service and ministerial codes”.

Sir Brian said even if the review concluded non-statutory codes were enough,  the Government “should nonetheless introduce a statutory duty of accountability on senior civil servants for the candour and completeness of advice given to permanent secretaries and ministers, and the candour and completeness of their response to concerns raised by members of the public and staff.”

In his study, Sir Brian called for permanent memorials to the victims of the infected blood scandal, including one for the children of Treloar School, where dozens of pupils died from hepatitis and Aids after being given infected blood.

He further said a permanent memorial should be put in place in the UK, with consideration of whether others should be created in Northern Ireland, Wales and Scotland.

Further recommendations are for bodies such as the General Medical Council and NHS England to ensure “lessons learned” are incorporated into doctor training.

“They should look favourably upon putting together a package of training materials, with excerpts from oral and written testimony, to underpin what can happen in healthcare, and must be avoided in future,” the report said.

On Monday, Sir Brian vowed to “do what I properly can within my powers” to prevent “unreasonable delay” in the Government response to his report.

He concluded his statement by saying: “It may be late, but it is not too late: now is the time, finally, for national recognition of this disaster, for proper compensation and for vindication for all those have been so terribly wronged.”

Reports have suggested an infected blood memorial on display at the inquiry until its hearings finished in February will be permanently rehomed at some point.