NHS Providers response to the Clare Marx review of gross negligence manslaughter and culpable homicide
NHS Providers welcomes the opportunity to submit a response on behalf of the NHS trust provider sector to the GMC's consultation on gross negligence manslaughter and culpable homicide. We support the ambition of the NHS to build a just culture, where there is a focus on learning rather than a retributive culture characterised by punishment and blame in response to honest mistakes. This is essential to improving patient safety and identifying barriers that prevent meaningful changes that deliver high quality care. We also support a systems approach to safety, underpinned by a human factors perspective which recognises the significance of the working environment to the context and circumstances surrounding a patient safety incident resulting in death. Only thought such as approach to investigation can we ensure that doctors will not be unfairly prosecuted.
Trusts take a range of approaches to local investigation, which are influenced by the capacity of local staff, investigative skills, clinical expertise, and nature of the incident to be investigated. We recognised that not all investigations are conducted with the requisite skill and expertise, or with appropriate involvement of families and that this compromises the clarity and quality of the investigations and the learning that flows from the. Trusts are committed to improving the quality of the investigations and have provided examples of approaches they are taking to ensure impartial investigations are undertaken by skilled investigators and that learning takes place. However, many trusts have also experienced a rise in concerns amongst their doctors that they are at increasing risk of unfair blame for patient safety errors made more likely due to resources constraints.Download