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6 June 2019, 08:25
Hospitals should be scrutinised as part of investigations into doctors following the unexpected deaths of patients, an independent review suggests.
The report, commissioned by the General Medical Council (GMC), calls for a shift towards "a just and fair culture when things go wrong", to better support staff and improve patient safety.
It also suggests the need for the medical regulator to rebuild its relationship with doctors, in light of the backlash over the case of Dr Hadiza Bawa-Garba.
Leslie Hamilton, chairman of the independent review of gross negligence manslaughter and culpable homicide in medical practice, said: "Over the last 20 years we have repeatedly heard this call for a change in culture from patient safety experts and multiple reports. But nothing much has changed.
"We hope our report will be the tipping point and this long-awaited change to a learning culture will finally happen."
Mr Hamilton said the case of Dr Bawa-Garba spread "toxic fear" through the profession, and led to a loss of self-confidence among doctors.
The trainee paediatrician was found guilty of gross negligence manslaughter in 2015 over the death of six-year-old Jack Adcock at Leicester Royal Infirmary from sepsis in 2011.
A tribunal decided she should remain on the medical register despite her conviction, but the GMC faced an outcry from doctors after it took the case to the High Court and she was struck off last January.
Many doctors complained important issues raised by the case - including dangerous levels of understaffing, failures of IT systems, and staff being required to work in inappropriate conditions - had been ignored.
In August last year, the Court of Appeal ruled Dr Bawa-Gaba should be restored to the medical register, and in April, it was decided she could practise again.
"Although the relationship between doctors and the GMC had been deteriorating for some time, what finally triggered the wave of anger was the action of the GMC in successfully appealing the decision of the Medical Practitioners Tribunal Service (MPTS) not to erase her name from the medical register," Mr Hamilton said.
In its review, the working group found evidence of "poorly conducted local investigations" following unexpected deaths, with a focus on individual blame.
Among its recommendations, it suggests that when doctors are investigated for gross negligence manslaughter or culpable homicide "the appropriate external authority should scrutinise the systems within the department where the doctor worked".
"Where the doctor is a trainee, this should include scrutiny of the education and training environment by bodies responsible for education and training," the report adds.
"The NHS is one of the safest health systems in the world, but it can be better," Mr Hamilton said.
"And the way to improve patient safety is to change the attitude when things go wrong and errors happen, instead of blaming an individual, we learn from that and we make the system safer."
The review also calls for the GMC to "take immediate steps to rebuild doctors' trust".
Charlie Massey, GMC chief executive, said: "The report says we must rebuild trust with the profession, and we fully accept this challenge.
"Having reflected as an organisation, we are committed to acting on that and taking forward all the recommendations in this report directed to us.
"We share this report's desire for a just culture in healthcare and acknowledge that we have a crucial role in making that happen.
"We are already making progress. Work is underway to address some of the key issues raised in this report but there is plenty more for us to do."
He added: "If we all act together, this report can be a catalyst for a step change in achieving a just culture in healthcare."