Final Report > Chapter 26: The Safety of Care > Overcoming the barriers to openness > Reporting systems

Reporting systems

36 Within the NHS itself, a policy of reporting sentinel events which is both open and non-punitive should be pursued. (By a non-punitive policy we mean a policy which expressly indicates that the NHS prizes information and it will not punish those who report errors, including their own, except in circumstances of criminal behaviour.) The adoption of such a policy need not await the outcome of the examination of clinical negligence litigation, although any system of reporting will remain imperfect until that wider issue is tackled.

37 What we envisage through this policy is the creation of a new compact of trust between the hospital and the workforce, made in the cause of patients' safety. Healthcare professionals must be able to know that they can come forward. They must feel safe to do so. The hospital must continually reassure them by its actions that this is so. Of course, patients also must come to understand and accept this process. They will first need to be persuaded that lessons are, in fact, learned and that, where they have been harmed, they can and will receive their due, whether it be an apology or compensation, without the need for clinical negligence litigation. But, according to Professor Leape, the public will accept it. He points out that the public's principal interest lies in what is being done about a problem. They do not expect perfection, they accept that things can go wrong, but they do expect honesty and action. [32] To bring about this change of policy, indeed of philosophy, will represent a major challenge of leadership. The NHS and trusts must make it clear that they will not criticise but, indeed, prize those who report errors. Only where there is criminal behaviour (which thankfully is very rare), will there be a place for blame.

Footnotes

[32] See report of Seminar 6, Annex B