Letters

Open letter to the chief medical officer

Learning from Bristol: the need for a lead from 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 usand many other doctorsis 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.

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.

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.

1.	Learning from Bristol. The report of the inquiry into children's heart surgery at the Bristol Royal Infirmary, 1984-1995. London: Stationery Office, 2001. (www.bristol-inquiry.org.uk/final_report/index.htm)
2.	Halligan A, Donaldson L. Implementing clinical governance: turning vision into reality. BMJ 2001; 322: 1413-1417[Free Full Text].
3.	National Health Service. A commitment to quality, a quest for excellence. Available at: www.doh.gov.uk/cmo/cmoh.htm
4.	Department of Health. An organisation with a memory: report of an expert group on learning from adverse events in the NHS chaired by the chief medical officer. London: Stationery Office, 2000.
5.	Department of Health. Building a safer NHS for patients: implementing an organisation with a memory. Available at: www.doh.gov.uk/buildsafenhs
6.	Mayor S. NHS introduces new patient safety agency. BMJ 2001; 322: 1013[Free Full Text].
7.	NHS Executive West Midlands Regional Office. Report of a review of the research framework in North Staffordshire Hospital NHS Trust ( Griffiths report). Leeds: NHS Executive, 2000. (www.doh.gov.uk/wmro/northstaffs.htm, updated 8 May 2000.)
8.	Hey E, Chalmers I. [With commentary by R Griffiths, T E Stacey, J Struthers.] Investigating allegations of research misconduct: the vital need for due process. BMJ 2000; 321: 752-756[Free Full Text] and 1348-9.
9.	North Staffordshire NHS Trust. Hansard 10 October 2000, cols 150-1.
10.	Evans R, (chair). The report of the independent inquiries into paediatric cardiac services at the Royal Brompton Hospital and Harefield Hospital. London: Royal Brompton Hospital, 2001.
11.	Donaldson LJ. Doctors with problems in an NHS workforce. BMJ 1994; 308: 1277-1282[Abstract/Free Full Text].
12.	Jones J. Hospital doctors face rising threat of suspension. BMJ 2000; 321: 72[Free Full Text].
13.	Suspension of Hospital Medical Practitioners Bill. Hansard 12 April 2000, cols 273-9.
14.	Smith R. Babies and consent: yet another NHS scandal. BMJ 2000; 320: 1285-1286[Free Full Text].
15.	Dyer C. Hospital chief was right to release patient consent forms to media. BMJ 2001; 322: 1266[Free Full Text]. (26 May.)
16.	Ferriman A. Paediatrician to be reinstated. BMJ 2001; 322: 1085[Free Full Text]. (5 May.)
17.	Anonymous. Recommendations for suspended doctors must be enacted. BMJ 2001; 323: 47[Free Full Text]. (7 July.)
18.	Department of Health. Supporting patients, protecting patientsa consultation paper on preventing, recognising and dealing with poor clinical performance of doctors in the NHS in England. Available at: www.doh.gov.uk/cmoconsult.htm (para 2.51)