Don Berwick is a leading expert in Healthcare and Patient Safety and, as has been widely reported in the media, was an advisor to President Obama when devising his US healthcare plan.


Following the Francis Report into the Mid-Staffordshire scandal, the government invited Mr Berwick to conduct a review of patient safety within the NHS and his report has now been published. In addition to the report itself, he also published letters; to the staff within the NHS, to the people of England and to politicians, senior clinicians and healthcare leaders.


His letter to the government and healthcare leaders summarises his findings and recommendations into what must be done, how it should be done and who should do it. The ‘what’ consists of four guiding principles, for which many in the press have already criticised him as offering no more than woolly principles. However Mr Berwick recognises that the NHS is a complex organisation and change for the better will not be achieved overnight. Importantly he also advised that it does not require further organisational re-structuring. He is used to dealing with politicians and within these 4 guiding principles, he reminds politicians that the safest and best way to lower cost, is to put the quality of patient care and safety above everything else.


The ‘how’ involves a move away from the ‘blame culture’ and a recognition that human error does occur even where otherwise well-intentioned staff are doing their best. Importantly he emphasises that there should be accountability and recognition of harm caused but within the NHS, such incidents should provide a learning experience so that the error is not repeated. However, he agreed with Robert Francis QC that wilful or reckless harm should be punished with criminal sanctions.


The ‘who’ part requires all staff, managers, healthcare leaders and politicians to put patient safety first.  It also calls on government and leaders to focus more on the growth and development of all staff, to focus on learning and improving their skills in order to ensure quality across the service.


For most people who experience unexpected harm as a result of medical treatment, that harm will likely have been the result of human error rather than deliberate or wilful neglect. However, the complaints handling process can vary widely from one Trust to another and overall, patients express dissatisfaction and frustration with the delay in dealing with their complaints. The culture of openness, transparency and accountability which both Robert Francis QC and now Don Berwick advocate is still some way off.


Unexpected injury as a result of medical treatment is a profoundly upsetting experience, since patients submit to treatment aware of the risks but trusting the clinicians to protect them for unexpected harm.  Where the harm results in a death, the experience becomes a nightmare for relatives. Until a complaint is met with a prompt clear explanation as to what went wrong and if appropriate, an apology is made, many patients or their relatives are left with no choice but to pursue a claim in clinical negligence in order to get answers to their questions and if they can establish negligence, compensation for their pain and suffering.


If you or a member or your family have been injured or suffered unexpected complications as a result of medical treatment, contact Suzanne Gallagher at Devonshires on 020 7880 4707 for a confidential discussion.”