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| 1 |
ID:
167898
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| Summary/Abstract |
If one of the key reasons for an inquiry is to learn lessons and prevent similar events from reoccurring, recommendations must be implementable and implemented, but it is clear that lessons have not been learned and recommendations not implemented. This paper compares the ‘implementability’ of recommendations from the three inquiries of Ely, Bristol and Mid Staffordshire to stress the importance of learning lessons. It examines two broad issues of ‘who?’ and ‘what?’. First, some 80 per cent of the Ely recommendations were aimed at the institution, while 72 per cent of the Bristol and Mid Staffordshire recommendations were aimed at the system. Moreover, about 7 per cent of Ely's forty‐four recommendations have a clearly identified agent, compared to 15 per cent at Bristol and 41 per cent at Mid Staffordshire. Second, the policy tool of ‘sermons’ accounts for some 89 per cent of Ely recommendations, compared to 66 per cent at Bristol and 63 per cent at Mid Staffordshire. However, the earlier sermons did not appear to prevent the events at Mid Staffordshire occurring. Pulling these issues together, it can be suggested that, given the large number of potentially responsible agencies, recommendations should be ‘active’ with a clearly identified agent and that a clear policy tool or mechanism should be identified rather than rely on a vague tendency to sermonise.
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| 2 |
ID:
167897
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| Summary/Abstract |
There is little research focussing on how bereaved families experience NHS inquiries and investigations. Despite this gap, there is a consistent assumption that these processes provide families with catharsis. Drawing on my personal experiences of NHS investigations over a five‐year period after the death of our son, Connor Sparrowhawk, I suggest the assumption of catharsis is misplaced and works to erase the considerable emotional ‘accountability’ labour that families undertake during these processes. I further question whether inquiries or investigations are an effective way of holding stakeholders to account. I conclude with two points: first, qualitative research is needed to better understand bereaved family experiences of inquiries and investigations and second, the ‘lessons learned’ objective underpinning inquiries should be replaced with ‘leading to demonstrable change’, which is what families typically want.
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| 3 |
ID:
167894
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| Summary/Abstract |
If inquiries are about learning the lessons of the past, why do they appear to find the same failings time and again? Bristol, Mid Staffordshire, Morecambe Bay, Liverpool Community Health are all examples of where culture went wrong. The lack of learning from inquiries is a prominent concern and one raised elsewhere in this issue. In this article, I explore why it might be that culture is repeatedly found to be the cause of healthcare failures. I start by reviewing perspectives on what culture is and the degree to which it is possible change it. I examine how culture was described in the Bristol, Mid Staffordshire, Morecambe Bay and Liverpool inquiries and question whether these are the same cultures, with the same problems, or whether they are different. I discuss possible explanations for apparent similarities, describe how cultural change occurs and conclude by drawing out the implications of focussing on culture as a threat to patient safety.
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| 4 |
ID:
167896
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| Summary/Abstract |
Opportunities for engaging the public have changed over the fifty years since the inquiry into the Ely Hospital, Cardiff. NHS inquiries, and inquiries more widely, tend to be called where events have led to public concern and loss of public confidence. Involvement of the public could therefore be assumed to form a part of restoring that public confidence. This paper explores the mechanisms for public involvement in NHS inquiries over the past fifty years, assessing the roles played by the public. It uses the framework outlined by Geoffrey Howe to examine how members of the public have been involved in four NHS inquiries. Findings suggest that the roles and mechanisms have varied, but that understanding the extent of public involvement is a dimension to assessing each of the potential functions of an NHS inquiry.
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