13/1/16 No Blame Culture

I find myself wanting to write about the 'no blame culture' we are told must exist within the NHS.
I believe the phrase ‘no blame’ is confusing for grieving parents, and in many cases, frightening and antagonistic.

I certainly felt like this initially.

Part of the reason for this I believe is that there was no one contacting me about the errors that were made, I had to identify them myself and ask questions about them. Also, I received wishy washy and vague answers to my questions, and wishy-washy vague SUI/RCA documents relating to Jasmines situation.
Also confusing were phrases like x should not have happened ‘but there is nothing to say if it had not happened this would have changed the sad outcome’ when it seemed clear to me it most certainly would have done.
I feared that nobody wanted to accept any ‘errors’ were to blame for what happened in case this affected their ability to defend a legal claim. (I still fear I may have been right about this) I thought the ‘no blame’ idea related to this. That the NHS would accept it made mistakes, but never accept they were to blame for the harm. “Don’t blame the error for what happened otherwise we might get sued.”

It strikes me that a clear distinction needs to be made. You can (and should) identify and blame the error, the 'act or omission’ for the harm, but very often it is not appropriate or fair to blame the 'person' who carried out that act. There is a bigger picture when it comes to why that person made that error. This distinction needs to be made clear to everyone, the public and NHS employees.

I wish I had been told what error was to blame, and why ‘system failures’ had led to the error being made by the individuals who made it early on in my case. I would of known ‘what’ was to blame, and why ‘it’ had happened.

I know that my child was given a drug without the necessary checks, which put her at risk of harm. In Jasmines case she did not have her blood pressure checked as part of her regular observations, even though this was THE observation that needed to be paid close attention to when being given the drug she needed.

Jasmine then developed alarming symptoms and seizures, which the consultant believed might be due to Hypertensive Encephalopathy, when the blood pressure becomes so high the brain is affected. I later discovered that Jasmine already had high blood pressure before being given the drug, putting her in the at risk group for developing this kind of complication.

It was only natural for my initial question to be "who is responsible for this" In my haste I concluded as so many would that the two nurses who gave the medication without checking her blood pressure were to blame, they didn't do their jobs properly.

I no longer blame the nurses. I blame the lack of BP monitoring. I see the distinction. I have developed for myself my own understanding of what 'system failure' means in my case, but with openness and honesty about what had gone wrong, I probably needn’t have had to come up with this myself.

Looking at what happened to Jasmine, it is my best guess that on that ward it was common practice to leave out BP when doing a set of observations. Especially at night when a child was sleeping, or if a child was upset, the assumption being it was kinder to let them sleep, or an accurate reading would not be obtained if they are upset. I know this is common thinking and practice nationally.

If this was common practice on that ward, then all members of staff, including nursing sisters, and consultants, were condoning it by not pulling people up for missing it out. Therefore the whole 'system' was one that did nothing about this potential patient safety issue. The whole system was feeding into those two nurses understanding of BP monitoring, and when it was OK to leave it out. Most probably the reason being that omitting the BP (whilst not right) wasn't resulting in any harm to any children, and in many cases (for example the sleeping child) was considered kinder to the patient.
The problem with safety-efficiency trade offs like these of course, is that whilst in 99.9% of cases it isn't an issue, in a different set of circumstances, when staff lack situational awareness, a tragedy can occur.

This was what I think happened to Jasmine. There was no situational awareness that it was not OK to leave out the BP for her. She was already a 'use with caution patient' because of her previously high BP but staff were not aware of this. (There is another system failure to explain how this happened no doubt)
Jasmines last line of defence was for her BP to have been measured as part of her basic obs before during and after being given the drug. The need to do this was in the safety guideline for giving the drug. But the guideline wasn’t followed, to this day I don’t know why. However, it wouldn’t have mattered about the guideline if the staff on the ward were thorough about making sure all basic obs were undertaken as a matter of course. But my assumption, as I have explained, is that they were not.

If I am right then it is not therefore fair to single out the nurses who didn't do it for Jasmine and say their error that night is entirely their own fault because it's the fault of that entire ward team or ‘system’ that it had become accepted practice to leave it out. This would be something those nurses had done many times before with no consequences and no one telling them it was wrong, It could probably have been any nurse that night, but they were the ones that were caught out. It's not fair to single them out for punishment when everyone had been doing the same and they were the unlucky ones to 'get caught out'. The only right thing to do after an incident like this is to inform all the staff of the error and it’s
consequences, point out it could have happened to any one of them, and to all agree from this point forward all basic observations must be done on all children as a matter of course. That, and to offer emotional support to the two nurses carrying the burden that they were the ones whose patient suffered.

Of course the other only right thing to do would be to contact us, and inform us of the very same. Tell us the ‘act’ of leaving out the blood pressure was a serious error and is to blame for putting our child at risk. Tell us this was something that had become common practice on the ward, without any consequence, until now. Tell us how much regret there was that Jasmine’s suffering had to occur before the practice was recognised to be dangerous, and explain that this would no longer be happening. Tell us the individuals involved, and all ward staff, were aware of what had happened and why and were deeply deeply sorry.
We would know ‘what’ had happened, and we would know the ‘how’s and why’s’ as well as what was being done about it.

‘No blame’ is a scary term for grieving parents like me. Parents need to know ‘what’ is to blame. They need to know ‘why’ it occurred. Mostly, they are able to understand it is not fair to single out and discipline an individual, provided an exhaustive explanation of all of the factors influencing that persons decision making is given to them.

The ‘no blame’ culture is a good thing. It just needs to be clear that we can blame ‘what’ just not ‘who’. We all need to understand this, avoidably bereaved parents so that we are not antagonised or frightened by the idea of no blame, and the NHS so that no blame is not used as an excuse to get away with no candour.

Joanne Hughes
Mothers Instinct