In December 2016, Jeremy Hunt, the Health Secretary, stated that he would introduce legislation that would force Trusts to collect, estimate and publish data about their number of preventable deaths. This data would be published “quarterly, along with evidence on what resultant “learning and action” has been taken, so that “local patients and the public can see whether and where progress is being made”. NHS Improvement will also be asked to collect this information at “a national level” (Health Service Journal, 13 Dec 2016). He reiterated this on the 14th December 2017 in a radio interview albeit with some changes such as no longer publishing league tables.
While this transparency is no doubt important and patients’ families deserve to know what happened there are several important potential consequences for healthcare staff that should not go unnoticed. “Learning and action” as a result of the preventable death is essential. What is also essential is to provide support to healthcare staff who have been involved in this preventable death and to recognise the impact on them of this openness and transparency. According to Mr Hunt, it will be easier to focus on preventable deaths in those hospitals who have an internal culture which supports this openness. While he acknowledges the fear of intervention by the GMC, CQC and of litigation, does hinder the process, what is absent is an acknowledgement that changing the culture and managing this fear is exceptionally difficult – it requires resolve, time and money. Add to the mix the impact of social media and the complexity increases.
The second victim
A phenomenon that we have become increasingly interested in as we continue to review teams in difficulty, and in our work with individual doctors who are in difficulty, is that of the second victim, the first victim being the patient and their family. This term ‘second victim’ was coined by Wu (2000) and has been defined by Scott et al. (2010) as “a health care provider involved in an unanticipated adverse patient event, medical error and/or a patient related-injury who becomes victimised in the sense that the provider is traumatised by the event. Frequently, second victims feel personally responsible for the unexpected patient outcomes and feel as though they have failed their patient, and feel doubts about their clinical skills and knowledge base.” Within this taxonomy, the third victim is the organisation which may suffer reputational damage as may managers and executives who represent the organisation.
The second victim, who may be a doctor/nurse or any healthcare provider, may suffer both professional and personal harm and experience symptoms that are akin to PTSD (Post Traumatic Stress Disorder). Symptoms that would fall under the professional banner are lack of confidence, concern for what colleagues think about you and your capability; uncertainty about competence, anxiety about what patients might think. Those which fall under the personal banner include typical symptoms of PTSD such as trouble sleeping, flashbacks, nightmares, anxiety etc. The impact on the victim’s family is also a factor.
Given the current and increasing pressures on the NHS there is often little time to provide the necessary organisational support to those on the front line who bear the brunt of these incidents, including trying to contain the patient and relatives’ emotional demands and expectations. Debriefings about what should have happened, or an RCA (Root Cause Analysis) into what went wrong typically do happen. Little, if any attention, however, seems to be paid to the emotional/psychological impact of the incident on the doctor or nurse. Schwartz Rounds go some way to providing the space for these issues to be discussed but it is unclear if those who are most affected by incidents do attend these Rounds. In addition, we know anecdotally that many doctors consider themselves “resilient” and apparently with little need for support. The subject matter seems taboo and we have heard examples of senior consultants exhorting junior doctors who become upset to “just get on with it”.
Providing a safe and contained space and process for discussing these very challenging issues should be part and parcel of what the organisation provides to ensure staff health and wellbeing. Changing the culture and finding the time in the highly pressured and constantly measured NHS makes this challenging but no less important.
by Dr. Megan Joffe