Dr Kim Holt, Consultant Paediatrician and Founder of Patients First

Having worked in paediatrics now since 1984, I am disturbed to discover
that the NHS has become increasingly defensive and resistant to
learning. It has been particularly hard to discover colleagues
behaving in ways that one might never imagine, and superficially it
appears that they have seemed prepared to do almost anything to ensure
their own survival over and above any other outcome. I really hope that
now is the moment in history when the culture will change.

Having observed during my own journey, the dynamics of teams and
organisations, and thought a lot about why things go wrong, my main
conclusions are related to the fact that we are human beings working in
challenging and emotionally charged situations which we respond to in
human ways. The ignoring of child abuse is the classic example where a
health professional has ignored obvious signs of abuse, and one wonders
why? The psychological defense of denial is powerful, none of us
being immune to blocking out what might seem obvious to others.
Unconcious processes within teams and problematical relationships
between professionals and parents can lead to difficulties that may
unintentionally cause harm to children.

Doctors are highly trained professionals and none want to make
mistakes, but they happen many times over. We work in multidisciplinary
teams in often less than satisfactory environments, with challenges
that our forefathers could not have imagined. We face structural change
and targets imposed from above that have at times taken priority over
patient safety, and many of us have become demoralised. The importance
of the organisational culture to safe and effective health care is now
being recognised. Yet we see ongoing denial about the data presented
or the facts detailed in public inquiries. It just seems to be very
hard to accept that we make mistakes. We get things wrong, bad things
do happen. Complexity and stress will increase risk, and these human
factors do need to be understood better to ensure that we can provide
as safe care as possible for children and families.

We have to get over this. It will be painful for the NHS but the only
way forward now is to learn and use the patient stories to continually
I shall definitely read the stories and encourage trainees and
colleagues to look at them, at least to try and improve our practice.

Mothers instinct has grown out of unbearable sadness, nothing can be
worse than losing a child, but the courage of the founder of this
website and their tenacity will I am sure benefit children for many years
to come.

Dr Kim Holt
Consultant paediatrician London.