Reducing the risk of NHS disasters

Abstract

How could we better use public inquiries to stem the recurrence of healthcare failures? The question seems ever relevant, prompted this time by the inquiry into how former nurse Letby was able to murder newborns under National Health Service care. While criminality, like Letby’s, can be readily condemned, other factors like poor leadership and culture seem more often regretted than reformed. I would argue this is where inquiries struggle, in the space between ethics and law—with what is awful but lawful. In response, we should learn from progress with informed consent. Inquiries and civil litigation have seen uninformed ‘consent’ shift from being undesirable to unlawful. If better leadership and culture were sole drivers here, we would likely be doing far better in many other areas of healthcare too. Instead, one could argue that progress on consent has been made by reducingepistemic injustice—by naming and addressingepistemicissues in ways that enhancesocial powerfor patients. If this is an ingredient that transforms clinician–patient working, might it also shift conduct within other key relationships, by showing up what else should become unlawful and why? Namingmedical paternalismmay have helped with consent reform, so I continue this approach, first naming two areas of epistemic injustice:management feudalismandlegal chokeholds. Remedies are then considered, including the democratisation of management and reforms to legal ethics, legislation and litigation. In brief, public inquiries may improve if they also target epistemic injustices that should become unlawful. Focus on informed consent and epistemic relationships has improved the medical profession. Likewise, it could help healthcare leaders shift from fiat towards consent, and their lawyers from a stifling professional secrecy towards the kind of candour a prudent public expects.