Open letter to the chief medical officer

Dear Professor Donaldson,

The long awaited report of the inquiry into children's heart surgery at the Bristol Royal Infirmary has now been published. The report echoes many of the themes that you have developed and reiterated since you became chief medical officer. It notes, for example, that “error, once acknowledged, allows lessons to be learned” and that “learning from error, rather than seeking someone to blame, must be the priority.”¹

You have also recently explained in the BMJ how clinical governance will facilitate the delivery of quality care, which should be characterised by “a no blame, questioning, learning culture, excellent leadership, and an ethos where staff are valued and supported as they form partnerships with patients.”² Similarly, in the letter you sent to every doctor last month, you noted that there had not been a real appreciation of the frequency with which, when things go wrong, “the true cause lies in weaknesses within the system rather than culpable actions of an individual.” Your letter also drew attention to a statement recently issued on behalf of the government, the medical profession, and the NHS which emphasised “the need to acknowledge ‘honest failure’” and that “the first response should not be blame and retribution.”³

Few would wish to criticise your frequent promulgation of these principles.^2–6 What puzzles us—and many other doctors—is why you and your colleagues in the civil service and government have not ensured that you use opportunities to set an example of the behaviour you expect of others. This open letter reflects our frustrating failure to be allowed to discuss these matters with you informally.

Admitting systems failure

Two days after the report of the Bristol inquiry appeared, a medical civil servant named in the report insisted on Radio 4 that the inquiry team was wrong to say that he “should have behaved differently.” This is simply the most recent example of an unwillingness among civil servants to admit errors and to acknowledge the systems failures that these often reflect.

Over a year ago now, we sent you an advance copy of our assessment of the quality of an inquiry prompted by allegations about research on children in Stoke on Trent.⁷ Our draft report suggested that an inquiry team composed of two senior medical civil servants and one lay member had disregarded due process and produced a report that was full of factual errors and repeatedly blamed named individuals. Our purpose in making the findings of our investigation available to you well in advance of their publication in the BMJ ⁸ was to ensure that we were able to correct any errors of fact in our report and also to give the department an opportunity to respond to our findings, indicating what systems might be put in place to avoid a recurrence.

A year later, none of our specific allegations has yet been refuted, either by the inquiry team or by the department. Worse still, in response to questions raised in the House of Lords about the quality of the inquiry, the minister responsible said he had “no reason to believe that the review was not conducted properly” and did not believe that it was “out of order or kilter with others which have taken place, or are taking place, within the NHS.”⁹

The systems failure for which the department was responsible in this instance has never been openly admitted, but its nature was made very clear in the report of the inquiry into cardiac surgery at the Royal Brompton and Harefield Hospitals published earlier this year. The chapter describing their guiding principles and procedures begins: “We found there was neither precedent nor guidelines to draw on to help us run the Inquiry. This is surprising given the number of non-statutory reviews commissioned within the NHS.”¹⁰

Scapegoating

In 1994, based on your experience as a regional medical officer, you wrote in the BMJ that you had not resorted to suspension of NHS staff unless there was an immediate danger to patients. Your judgment then was that suspension “introduces an immediate stigma, increases the degree of confrontation, and makes informed and agreed solutions much more difficult.”¹¹ Commenting on another consequence of prolonged suspension in 1995, the current secretary of state, then a backbencher in opposition, is reported to have suggested that the prolonged suspension of a paediatrician in London had been an “expensive shambles for the NHS.”¹² The Society of Clinical Psychologists says that the NHS suspended as many doctors in 1997-9 as in the previous 10 years, but incompetence was found on investigation in only 1 in 10 of those so charged.¹² Clearly, allowing these doctors to continue working would not have posed “an immediate danger to patients”—your only criterion for justifying immediate suspension. The government resisted attempts to get a bill curtailing prolonged suspension passed 16 months ago¹³ but has yet to announce a plan for curbing this practice.

The worst accusation levelled at the doctors and nurses in Stoke was that some research consent forms had been forged—an allegation that received very wide publicity, including an editorial in the BMJ.¹⁴ The General Medical Council has now ruled that these allegations were entirely false.¹⁵ . . . If the Department of Health and managers at the NHS Trust really “valued and supported” the nurses and doctors in Stoke, they would have ensured wide publicity for this finding by now. One of the doctors in Stoke who was suspended 20 months ago has been exonerated and finally went back to work last month¹⁶; another still remains suspended. . . . As you have made clear,¹¹ it is simply not possible to suspend NHS staff for months on end without prejudicing their reputations and destroying family life.¹⁷ While the Department of Health is aware that this can happen,¹⁸ it clearly does not share others' perception about the frequency with which suspension is seen retrospectively to have been inappropriate. A screening strategy that leads to more false positives than true positives risks doing more harm than good.

A request

The report of the Bristol inquiry concludes that “priority needs to be given to improving the leadership and management of the NHS at every level.”¹ You and your civil servant and ministerial colleagues are responsible for leadership and management at the highest level of the service. It may be unrealistic to expect ministers to acknowledge any responsibility for system failures. But are we also wrong to hope that the country's most senior doctor could ensure that medical civil servants lead by example in this respect? It was wrong of the team responsible for the inquiry in Stoke on Trent to try to deflect continuing concern over the conduct of their inquiry simply by saying in their commentary that many of their recommendations were sound,⁸ when many of the findings of fact were in error and they had ignored the need for due process.⁸ We now know that new management systems are currently being developed.⁵ Nevertheless, an open admission of past systems failure by civil servants would help everyone to see why new arrangements are necessary and make it easier for others in the NHS to make similar admissions.

Yours sincerely,