Learning from loss

Scott Morrish (second from left). Photo by Yaso Browne.

Leading up to Christmas, the Morrish family tweeted the account of how they lost their son, Sam, to sepsis.

In 2018, at the House of Commons, I heard Sam’s father at the launch of the “Learn Not Blame” campaign. He spoke movingly of his family’s loss and their will to improve safety.

“Sam’s death taught me that the NHS was not as safe as it could be. That when NHS competence was  threatened, its failure to truly understand Sam’s death or truly fulfill its duty of care to us or the staff that tried to save Sam, demonstrates failures of leadership and governance – first locally and then nationally.

There was a conspicuous absence of checks and balances against their misuse of hierarchical power. Accountability in the NHS was defective. Respect, compassion and care should be at the core of how patients and staff are treated. Not only because that is the right thing to do, but because patient safety, outcomes, experiences all improve when staff are supported, valued and empowered.”

Mr. Scott Morrish

The suffering of Scott’s family is profound. But when clinicians fail to share mistakes for wider learning, we risk this agony being transmitted to another unsuspecting family. Too often, concerns are suppressed, and institutions protected, at the expense of people. If the instinct of some judges is also to protect institutions, then reading the accounts of the Morrish family would serve as a powerful antidote. Great healthcare isn’t about defending institutions. It’s not just about saving the sick either. At best, it’s about saving ourselves from that sickness in the first place.

Imagine the suffering prevented by each death avoided; by each family who gets to take their child home, not through luck or particular skill but through candour over past mistakes.

But if candour is our vaccine against harm, then NHS management has a strong anti-vaxx movement.

For all the breathless wonder over stem cells, genetics and transplantation, we have to marvel at the ability of NHS management to perpetuate harm, by turning the blind eye and deaf ear, and by denouncing those who’d speak up. This flawed ecosystem is sustained if judges back institutions without fuller consideration of the children harmed or at risk.

In my own whistleblowing case, a judge described as child X someone whose preventable death was public knowledge. The child’s name was Caitlyn Parry. Left un-named, the lessons of her death are too readily forgotten.

Of course, judging such cases may not be easy. It may not be easy to stomach that major institutions have lied, about avoidable deaths in children, and about investigations that never happened. It may not be easy to admit that white surgeons, a traditional object of judicial admiration, are capable of altering evidence and plotting vengeance against brown whistleblowers. It may be too much to take, if society expects narratives set the other way round.

Hearings that hear

One way to support judges, and the public interest, might be to have them read victim impact statements in whistleblowing cases. Patients and family members would voice the impact of what went wrong. Such statements brought home the harm of surgeon Ian Paterson’s criminality. These personal accounts would also highlight the dangers of whistleblower suppression.

Seeing and believing

Videoing employment tribunals might also help. The public would get to see how whistleblowing matters. Judges might find “VAR” reduces the number of factual errors per judgment. If impact statements were also videoed, their learning could spread. In this way, recording tribunals could do as much for safety as videoing surgery.

If Caitlyn’s mum had been given the chance to explain what happened to her daughter, and how warnings were ignored, few tribunals would be inclined to gloss over managers’ lies about her case and others.

Likewise, the Morrish family face an unspeakable loss. They’ve spoken up to help protect us all. But their good faith and courage goes squandered, every time we shy from holding institutions properly to account.

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