Here, Liz McAnulty, member of the working group for the independent review of gross negligence manslaughter and culpable homicide (GNM & CH), speaks about the integral role that patients’ families played in the review and explains how patient safety is at the forefront of their recommendations.
In 2018, the General Medical Council (GMC) commissioned an independent review looking at how the laws of gross negligence manslaughter and culpable homicide are applied to medical practice across the UK. I was asked to be a member of the working group responsible for gathering evidence and data to shape the review and inform the recommendations.
I wanted to take part to further understand and put forward the perspective of patients’ families and carers, to ensure that their views were carefully considered as part of the review. I spent over four years working with the Patients Association to support patients and their families.
Through that experience, combined with a long career in health care and professional regulation, I am very aware of the suffering and trauma experienced by patients and their families, carers or those close to them, when things go wrong. This is exacerbated when they are not told the truth about what has happened, or worse, if there is a cover-up – as revealed most starkly in a significant number of inquiries into patient harm, such as Mid Staffordshire.
Enhancing patient safety
The review and our final recommendations were firmly rooted in enhancing patient safety. We know doctors work in challenging environments, where the risk of death is a constant one. The continuing and growing shortage of resources, especially staffing, in many parts of the UK, impacts significantly on both doctors and patients. This was raised by the public in independent research which we commissioned, and in the written and online responses to the review.
These issues add to the challenging working environment for doctors and other staff, and inevitably to the timeliness and quality of care received by patients. Ultimately, we want patient safety to be paramount, and we want doctors to feel supported to provide safe care.
It was important to us to consider everyone who has a role in the investigations into the unexpected death of a patient; and we wanted to gather as much information as possible on varying views and experiences.
One aspect we explored in detail was the experience of families and carers following the unexpected death of a loved one. We considered the impact of this distressing situation on the families, the doctors, and others involved in caring for the patient. We wanted to know what happened when things had gone wrong: how families were supported, how both systems and individuals were held to account and, ultimately, how an unexpected death might be prevented from happening in the future.
We listened to those who had direct experience of the unexpected death of a loved one. We held a dedicated workshop and oral evidence sessions for patients’ families and carers, which were open to people from all four countries of the UK. We received a number of written responses to our call for evidence from patients’ families and patient representative organisations. Finally, we also commissioned research to look at public confidence in doctors, which took into account views from over 2000 members of the public, in England, Northern Ireland, Scotland, and Wales.
This is an extremely difficult and emotional topic and we are hugely humbled by, and thankful to, those who shared their experiences.
The compelling evidence from families and carers highlighted areas which could be improved; and led us to make specific recommendations for local processes, including for coroners to ensure that families are informed, supported and involved at all stages of an investigation.
One area of particular concern was what happens immediately after an unexpected death of a patient. We found that families were not always fully supported. Many told us that they didn’t feel included in discussions or effectively communicated with. And we heard that when families feel excluded, they may also feel that the truth is being covered up, and are more likely to seek answers through legal processes.
Families can offer a valuable perspective in helping to understand what happened to their loved one throughout their care, including aspects which those investigating the unexpected death may not be aware of.
This is why we believe that effective engagement with families, carers or those close to the patient, from the outset of such an occurrence, is so important. There must be a clear process to explain what has happened and what will happen. This process should set out a named contact, and a channel of communication should continue following the outcome of a local investigation.
We also heard that many families believed the coroner service didn’t provide sufficient support for them. Although the reforms of the Coroners and Justice Act 2009 put families at the centre of inquests, we found that, in practice, this was not happening and many had lost faith in their local service.
Given the rarity of GNM cases, we concluded that it would be beneficial for coroners to receive greater guidance and training to make sure that, when they refer cases to the police, they are doing so consistently. This means the right cases are investigated by the police, and families and doctors alike are not put through unnecessary stress caused by a criminal investigation.
We also looked at the role and responsibilities of the GMC. One of its statutory objectives is to promote and maintain public confidence in the profession. In order to understand what the public expect of the regulatory process when a doctor has been convicted, we commissioned independent research.
The research showed high levels of public confidence in doctors. However, the findings also highlighted that the variation in the public’s view of medical error, rule violations and convictions, is complex. One of the main findings was that the public are acutely aware of system pressures, and that this can affect confidence in doctors being able to provide the best care. Due to the complexity of factors affecting public confidence, it’s important that the GMC continues to engage with patients and the public.
Embedding a just culture
Although I have touched on only a few recommendations in this blog, our report is focused on enabling a just culture to learn from mistakes and hold doctors and systems accountable, where appropriate. It highlights the patient-centred focus that organisations such as the National Quality Board and NHS Improvement have taken in co-producing guidance with families, to improve not only the NHS’s approach to unexpected deaths, but also the culture generally in healthcare.
We believe that all organisations and agencies can do more to engage with families and carers to recognise their insights as an important source of learning. By embedding a just culture, we can support doctors to speak openly and honestly and put patient safety at the heart of everything they do.
You can find out more about the report and how the GMC is responding to our recommendations.