Culture of covering up mistakes is a sickness within the health system

NOBODY says it better than Terry Prone.

Her article in yesterday’s Irish Examiner was about how medical professionals fail to respect the needs of patients and their loved-ones. It was profoundly important. The casual and often brutal styles of communication she described should have been eliminated years ago, but are still, all too often, the system’s centrepiece.

We criticise the Church, and banks, and nowadays charities, for covering up mistakes or wrongdoing. But how often are there cover-ups in our health system? The first instinct, when someone is hurt within the system, is self-protection. We must hide it, or minimise it, or deny it, or hush it up. It’s as if, when bad news has to be delivered, the only advice available is from some legal handbook that says “whatever you do, don’t incriminate us.”

The terrible tragedies that befell four families in Portlaoise General Hospital, resulting in the deaths of their babies, Katelyn, Joshua, Mark and Nathan, were appalling.

The report of the chief medical officer of the Department of Health, Dr Tony Holohan, explicitly describes the unacceptability of what happened. Dr Holohan uses a term I hadn’t heard before, but one that makes perfect sense. The term is ‘never event’ — simply, something that should never happen. Using his definition, Portlaoise Hospital had six ‘never events’. And four babies died. By any standards, that is unthinkable.

Nothing is worse for any family than the death of a baby — especially when there was no reason to even suspect there was something wrong. A death is a moment of enormous shock and pain, requiring sensitivity and understanding. Instead, the parents of these children got this: “there were clear descriptions where patients felt backs were being turned; honest accounts were not given; and unprofessional behaviours and language were frequent.

“Insensitivity and a lack of empathy were common themes. Younger patients were not so much spoken to directly as through their mothers, and had the feeling of being ‘judged’ by staff. There were even accounts of senior clinical staff (more than one) inviting families to ‘sue’. There was also a lack of cultural sensitivity. These accounts were not just applicable to the PHMS, but also to the paediatric unit,” Dr Holohan says in his report.

He also says there is an absolute obligation to disclose the fact of “harm, potential harm, or suspected harm as a result of an adverse event to a patient and/or family.” But he also says that the HSE’s own national disclosure policy is not yet fully in place.

That has a familiar ring to it. For many years, there have been really good child-protection guidelines in the health and social services systems. They’re now being put on a statutory basis. Why? Because there are too many people within the system who regard guidelines as something that can be ignored. We have too much experience in Ireland to deny that if something isn’t mandatory, even if it’s universally recognised as best practice, it won’t happen.

Of course, we might never have found out what happened in Portlaoise if it hadn’t been for a Prime Time TV programme, broadcast at the end of January. In the aftermath of that programme, and while an enquiry was being set up, the head of the HSE, Tony O’Brien, took the unprecedented step of writing a personal letter to each and every member of staff in the HSE. He also asked that his letter be forwarded to everyone working in organisations funded by the HSE.

In that letter, O’Brien referred directly to the Prime Time programme, and said “sometimes there are appalling lapses in the way we care for people, which can be hard to comprehend. All that is required is for each of us, without exception, to commit ourselves to one simple thing. What I am asking is that all of us, at all times, look after every patient or client with exactly the same level of consideration as we would if they were our parent, sibling, partner or child.

“In other words, just as we would wish to be treated ourselves. That is even more important when things have gone wrong, for whatever reason.”

You couldn’t but agree with the sentiments of O’Brien’s powerful letter. But he, and Holohan, both in different ways, refer to a culture that prevents this kind of humanity and compassion — and truthfulness — from being expressed.

Holohan says, on page 36 of his report, that his interactions with Portlaoise Hospital have caused him to wonder whether the culture of care has really changed, or if lessons have really been learned.

In his letter to staff, O’Brien says that “not enough has been done to create a common culture across the health services. Islands of excellence now share the same identity as significant under-performance and serious failure”.

Culture comes from the top. It’s true in the Church, it’s true in the banks, it’s true in business. A culture of openness and accountability starts with the leadership of any organisation. And a culture of accountability means different things. It doesn’t mean — and this is too often the case — that people should be afraid to admit mistakes, because they’ll be hung out to dry by the people who should have been managing them better in the first place.

Yes, if there’s to be real accountability in situations like Portlaoise, that means people who can’t do the job properly shouldn’t be allowed to continue. But punishment is not enough, if lessons aren’t going to be learned and applied.

People who own up to their mistakes are thin on the ground, and that’s no accident. The fear of repercussion has to be replaced by a much more supportive atmosphere, where people are encouraged to work through the consequences of mistakes.

But there is no excuse for the behaviour described by O’Brien as “apparently unfeeling bureaucracy, excessive defensiveness, and … serving only self-interest.”

In his own behaviour, especially in his approach to transparency in organisations funded by the HSE (the so-called Section 38 and 39 agencies), in his dealings with the CRC, and in his conduct at the Public Accounts Committee, O’Brien has practiced what he preaches. In doing so, he has shown real leadership in demanding and forcing a culture change.

It’s always harder internally. The culture of defensiveness is deeply engrained in large and bureaucratic organisations. We know, from our recent experience of whistleblowers, for example, how unwelcome they are within large organisations, and how the reaction to them is an instinctive circling of the wagons.

Change, although it must be led from the top, has to grow from the bottom up. Within the health service, it’s a job that has to be done ward by ward, hospital by hospital, office by office. Only then will we get a health service based on respect and trust.

But the people of Ireland are entitled to nothing less.