Leadership The Key To Learning From Tragedies

Main Category: Mental Health
Article Date: 22 Jul 2009 - 5:00 PDT

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Commenting on the Care Quality Commission's report into the West London Mental Health Trust, NHS Confederation Chief Executive Steve Barnett said:

"What happened at this trust is unacceptable. Some of the findings of the report show the organisation failed to care for often vulnerable people on a number of levels from staffing issues to the leadership of the trust.

"While this report concerns incidents that took place some time ago and we do not believe this is representative of mental healthcare as a whole, we must learn from what has happened here and make sure that the NHS provides the best support to an often challenging and vulnerable group of people.

"The Mental Health Network, which is part of the NHS Confederation, and its members will be working with the Care Quality Commission and the NPSA to help trusts make sure they learn from internal investigations.

"More widely, a number of the issues raised in this investigation follow on from previous reports as a call to action for the leadership of the NHS. We recognise that correct processes and reporting are not enough and must be backed up by a culture, led from the top, that encourages all staff to be open and involved in the process of learning and improving from when things go wrong.

"Along with its members, The NHS Confederation will explore how a process of board peer review might be set up to work alongside the regulatory system to help organisations learn from each other and drive through improvement.

"NHS Employers, part of the NHS Confederation, as founding members of the patient safety first campaign will be embarking on its goal to put quality and patient safety at the heart of all our work programmes.

"Ultimately, it is action that will lead to improvements for patients. Unfortunately the West London Mental Health Trust staff survey shows that the level of staff who feel able to report concerns could have been improved and we would strongly advise all trusts to review their actions around staff reporting concerns.

"Quality is now the organising principle for the NHS and the relationship between workforce, the environment they work in, the tools and equipment they use, and patient experience is a priority across the system. Staff need to feel able to report safely in an open and inclusive culture but this will only be of value if it leads to shared learning, meaningful analysis and recommendations of changes in how staff work.

"It has historically been very challenging to measure the nature of the climate and culture of working in the NHS. However, there are now tools to help organisations do this; such as the NHS staff survey and benchmarks on workforce engagement."

Source
The NHS Confederation

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