When Things Go Wrong – Understanding and Learning

The President: Ladies and gentlemen, tonight is rather a special night because we have with us Professor Sir Ian Kennedy, who is very welcome to our Society. Professor Kennedy is a Doctor of Law, an Honorary Doctor of Medicine and of Science, an Honorary Fellow of five Royal Colleges of Medicine, Emeritus Professor of Health Law, Ethics and Policy, University College London. For 13 years he was Professor of Medical Law and Ethics at King's College, University of London. He served on the General Medical Council (GMC) from 1984 to 1993. He served on the BMA Ethics Committee for nine years. He chaired the Bristol Royal Infirmary Public Inquiry from 1998 to 2001. He has written over 100 articles and papers. On a personal note, Sir Ian, in 1980 you were interviewed before the Reith Lectures; you promised to present “a critical analysis of the practice of medicine”. You described the BMA's Handbook of Medical Ethics as “anodyne, defensive and complacent”. I must say, at the time I agreed with you. But, best of all, you said the following: “What should a busy GP in Liverpool do when an unemployed man comes into the surgery asking for valium? You should not prescribe valium. It is not the doctor's remit to medicate social ills, to solve its political problems by zonking people out”, and I think you were absolutely right. Sir Ian, “When Things Go Wrong – Understanding and Learning”. (Applause.)

Sir Ian Kennedy: I am going, to a degree, to talk about Bristol. Here are two cases: One I will call the “Case of the Mop”. This was a case in which, in a particular hospital ward, there was an outbreak of infection which was very difficult to tame, it was rampant, very hard to solve, and the relevant people crawled all over the ward but in practice couldn't crack it, and eventually it came to pass that there was someone who was cleaning the ward who had two mops, one for the kitchen and one for the bathrooms. One of the mops had been taken, so she was cleaning the kitchen and the lavatories with the same mop, and the point of that story is that you could always blame the cleaner for doing such a daft thing, but you probably hadn't trained the cleaner to understand that that was a daft thing to do. Furthermore, why didn't she report straightaway that one of the mops had gone? Because there was a prevailing practice in that particular hospital that if you lost a piece of equipment it came out of your salary or wage packet. So you had an infectious disease outbreak in a hospital ward threatening the life, and taking the life, of some patients, all because of poor work practices, poor morale and ignorant staff.

Here is the other case. This is the case of a patient in Bed 6. Here is a nurse – it happened to be a man – and there are two sets of bays, each with three beds behind plastic curtains, and the supervising nurse asks the trainee nurse could he administer something to the patient in Bed 6, and he says “Yes” and he goes off and gets something. Unknown to him the patient in Bed 6 is moved and somebody else is in there. He goes in, introduces himself, as one should, administers a particular injection, as he was instructed to do, and then is informed that that wasn't the patient for whom it was intended and, furthermore, that patient has an allergy to the particular drug and he is going to have an allergic reaction. He is devastated, of course, and what you have got is a major medical mishap, a patient harmed because of a system which doesn't have within it the capacity properly to identify the relevant patient. You have also got a devastated nurse who is starting out on a career and realises that he has unwittingly and with the best possible of motives, done an awful thing to a patient. Nobody gets up in the morning to go to work to do something horrid to a patient. So you have done two sets of harm as a result of that situation. You will notice that I haven't used the language of “blame”, or any of that sort of language; I have just described two sets of circumstances in which the system of care was ill-organized, to detrimental effect.

I am now going to talk about Bristol. Some of you will remember that 10 years ago there was a big public inquiry. Do you remember that? This is a photo of Mr Wisheart being led out of the GMC surrounded by police. That slide shows a row of coffins representing what was then thought to be the number of babies who might have died. “Our children deserve the right to a public inquiry”. Well, that is what they got. And there is “Justice for Bristol”. I will go back to that slide.

There were three doctors in front of the GMC, Mr Wisheart, Mr Dhasmana and the Chief Executive, who was a chest physician. There were a number of deaths of young children undergoing paediatric cardiac surgery in Bristol over a period of time. Was the inquiry about three doctors, or was it much more complicated? I am going to seek to persuade you that it was much more complicated. The GMC, of course, had these three doctors in their sight: that was their jurisdiction, and all they could deal with was those three doctors in front of them. Two were struck off the medical register and one was suspended for a period of time and a limitation put upon his entitlement to practise; he was no longer to operate on young children; and he was a man who had trained in Alabama, one of the best places in the world, who had gone to Birmingham many times, where some of the best surgeons were; he was a dedicated surgeon, operating on children, and then by this suspension he was really grounded. If you don't continue to do that kind of work, you are not going to do it again, and as it happens, he has never done it again.

Or was it much more complicated than that, because that is what the GMC did, and the lecture is called “Understanding and Learning”, and I have taken you to the context. I am going to whizz through that again, because that is what the technology requires. So, if there was going to be a public inquiry, what was the concern of that inquiry? To try to produce a regime of care which was safe. Remember the mop? Remember the patient in Bed 6? And there are lots of other cases you can think of, and what we were trying to do in Bristol was understand what was going on so as to bring about safe care, and that was the whole thing that motivated the three years of that public inquiry – for that is how long it took. What approach should one adopt? You could adopt the approach of the General Medical Council, forced as they were down a particular jurisdictional route, or you could say, “Hang on a second. Let's see if we can find out a little bit more carefully what is going on here.” Enter human factors or systems analysis. What do these mean? They mean that when you look at things going wrong, it is wise not to, as it were, identify or pick out or say “X or Y caused this, and is to blame”. Let's try and understand the system within which that particular set of people had to operate. In the case of the patient in Bed 6 it was a somewhat chaotic, rather busy, “in and out” organization where patients were not sufficiently identified to those who had to look after them. In the case of the mop it was nothing to do with any blame, it was the fact that the cleaner had only got one mop and therefore became the agent for infection.

What are the human factors? How do we analyse what is going on? This is the work of a man that some of you will be familiar with, a man called James Reason who was a Professor of Psychology at Manchester. Most of his work was done in the aviation industry and in the oil and gas industry, trying to understand why, for example, the Piper Alpha event occurred, where 120-odd people were killed, or why aeroplanes fell out of the air, and he came up with the “Swiss cheese” notion: we all understand the notion of the “Swiss cheese”; that is, a piece of cheese with lots of holes in it, and the holes are serendipitously organized, they are not ordinarily aligned with each other, and that is the circumstance in which most people work, particularly when they work in risky environments – aviation, hospitals, chemical, nuclear, whatever industry – and the idea is that things go wrong when all the holes get aligned with each other, so that you begin this end, as if you are a rod, and you can get all the way through and, zap, you hit the target, and the idea is to make sure that you avoid that happening, or, if does happen, you mitigate it or you analyse it and minimize it. Take the scenario of the mop: you don't have a system where the cleaner has got to pay for it if she says, “I haven't got a mop”. Problem solved, because she then goes and says, “I haven't got a mop”, you provide another one free of charge and you don't have the infection. It is nothing to do with her, it is to do with understanding the system in which she worked.

What you have got to do is learn from your mistakes or possible mistakes: “we must treasure our errors”. That is the famous expression of a famous paediatric cardiac surgeon named Marc de Leval, who works at Great Ormond Street, and he doesn't mean to say “go around committing errors all over the place so that you can then say, ‘I've got a bigger treasure’”: what he says is that errors are inevitable, absolutely inevitable; it is a feature of the society and the complexity and the technological apparatus we have that we will make mistakes. The thing is to seek whenever we can to avoid them, minimize and mitigate them if they happen, to know what to do. So we treasure them and we have a system of openness; we embrace them, share them, learn from them; and the title is, you remember, “Understanding and Learning”, and that was the approach we adopted in Bristol. It took a very long time to get this across to an audience there, which was usually 200–250. I designed the hearing chamber so that we were sitting off to the side and people could come, as they did, and listen. They were usually parents. There were screens up where they could see all the documents that we could see. It was actually the first time that a parent was able to see the document that all those lawyers and people at the top of the room were talking about. Now you could see if paragraph 3 actually said that, and we could all see, and that was one of the principles of openness, that we were trying to convey the importance of understanding by reference to human factors and not by reference to blame. Blame is very attractive; it is very easy. It is completely unwarranted in most circumstances. There are some circumstances, but it is usually unwarranted because it operates on the principle of post hoc punishment, rather than a formalized system of accountability. To hold someone accountable means to say, “These are the rules pursuant to which you were supposed to do what you did, and this is to suggest that you haven't done that, looking at those rules. So, to that extent, we are holding you accountable against what we thought you ought to do.” Blame is post hoc, saying “Something has gone wrong, I'll have you, thank you”, and it is not usually fair, although it is very easy and it is much in vogue if you're running a newspaper or you're a lawyer, but we will come back to that.

There was a sentence in the report on Bristol which I insisted on putting in and insisted that the meeting understood it, and the sentence was: “This is not a story of bad people”. It was critical to say that. If you are going to understand you have got to understand; as I said at the press conference (there were about 400 journalists from all over the world), “If anybody here believes that any of these doctors or nurses or anybody else left home this morning thinking, ‘I'm going to go to work today and kill a child’, they are on a planet that I don't recognize”. They all left saying, “I'm going to do my best”, and that is what they were wanting to do. They were trapped in systems that didn't allow them to do that and they themselves were flawed, but they were not bad people. Blame would not allow you to understand, and therefore would not allow you to learn, and it would follow that, if you took those three doctors out of the system you had in Bristol and put three more in, within a very short period of time they would be doing exactly the same, because you hadn't addressed the right problem.

So if you are going to understand and learn from what happened in Bristol you have to examine the system of care, which was quite complex, and break it down. The choreography of the inquiry was such that we didn't invite the relevant doctors to give evidence until the end of the seventh month of the nine months of hearing, by which time we had set the scene so very clearly that it was about system, and so very clearly not about individual culpability, except where there was some degree of flawed behaviour. I will never forget one of the doctors. Each doctor gave evidence and we gave them three or four days if they wanted it. Mr Dhasmana was the last to give evidence, as a surgeon who couldn't crack an operation called a “switch”, and the child had died. That had caused everybody to say “stop”, and as regards each of these major witnesses I said they should have space at the end to say whatever they felt like saying. I wanted the “s” word and, if I couldn't get the “s” word, I wanted the “r” word, “sorry” or “regret”, because there were people out there. That wasn't to admit personal blame or culpability, it was to regret or feel sorry for what had befallen these people. Concerning Mr Dhasmana, I sent a message to his Counsel, saying, “Shut up…” (politely) “… and let him do what I think he's going to do”, and I got the message back saying, “I'll reserve my position on that”. When we had finished the evidence, I said to Mr Dhasmana, “We've heard from you and you have heard from us for a long time. Is there anything you want to say?” He got out a piece of paper, and I thought, “Here we go, he is going to read from a written script”, and he picked the paper up and put it by the side of him. During the whole of his evidence for four days the woman who was the Chair of the group of parents whose children had died (and she was supporting those – there were 200-plus parents in there) had sat in his eyeline. Wherever he might be looking, she moved, because he had operated on her child and her child had died. I sent a message saying that this was uncalled for, and intimidatory, and could she be asked to move. She did, she moved over there, and my Counsel was there and he was talking to her, and Mr Dhasmana put the piece of paper down. It was a grey late October/early November afternoon; it was about 4.30 pm; and I had given the instruction not to put the lights up, and to leave the blinds as they were. He looked straight at her and he said (and I am paraphrasing): “My career is over. I have no reputation, I have no standing, I have no job, I have no possibility of a job, my family are distraught and destroyed, I am distraught and destroyed. I have tried to get a job elsewhere; I can't get a job”. Then he looked her straight in the eye and said, “But my loss is as nothing compared with the loss of a child”, and it was as if … well, my co-judge, sitting here, she was holding my hand with her nails embedded in because of the emotional impact of that, and as soon as I could get myself together I said, “Thank you, Mr Dhasmana, we have all heard what you have said” and we all fled to our room. The woman whom he had addressed went to Sky News – there was a dedicated TV link – and said, “I always said it was a matter of systems, not personal failure of doctors”, and in football parlance that is called “getting a result”, because, if she realized that, you had persuaded those who needed to be persuaded, who needed to understand, who could then share that understanding with others. It was a very important step in the process of putting together those broken lives.

So that is a story. Am I all right to take you through some of the elements? They are quite interesting, and if you all nod off then you do.

The President: They are all wide awake; we are all wide awake.

Sir Ian Kennedy: Jolly good. I am just going to tell you a little bit about elements of risk. When you look at systems and how they work or not you always come back to leadership. When I was chairing the Health Care Commission and you looked into things that had gone wrong it was always poor, poor leadership, and in the case of Bristol, the Chief Executive had a particular approach to management, which was: “Don't bring me problems, bring me solutions”. That is what chapter 1 of Charles Handy's book on management is all about. I don't think he even got beyond chapter 1. Of course if you do have problems when you are a young trainee, where the hell do you go if you can't go to the chief executive and say, “I've got a problem”? It was a First Wave Trust. Do some of you remember what a First Wave Trust was? It was like a Foundation Trust in more recent times; you know, first past the post and all that. So where was the focus; where was his focus? On money, on breaking even, on being financially sound, and sometimes, while that is important … . Goodness help us, I was at a meeting of the Health Finance Management Association, or whatever they were earlier on in life, at the Grand Hotel in Central London, and money is important, but actually it's about people who are called patients. So that was the leadership's focus.

Then you had a Medical Director, who was entirely autocratic. He didn't see himself as autocratic, but he just didn't listen to anybody. He was very difficult to engage. And you had a Nursing Director who, in the witness box, described herself as the hospital's “rottweiler”. Now, okay, that is a style of leadership – it's called the “rottweiler” style of leadership, let's say – but it is not going to really carry, particularly when you're talking about an environment in which people are worried that children are dying here and you go to the Nursing Director because you've got a worry about how the theatre timetable is organized, and so on, and she says whatever she says. But they're all frightened of her, that's why they didn't go. We had virtually no evidence in Bristol from nurses on the record over these years, in my view, because she was the “rottweiler”.

So if you don't have good leadership, if you have leadership that allows bullying, which is so common in the National Health Service amongst nurses, if you have a leadership that says, “Don't bring me problems, bring me solutions”, as it were, then you're going to have a system led by someone who can't lead and the system is therefore at risk. It's like having a pilot who isn't very good at navigation.

And then you've got this popular term “governance”. How was the Bristol Royal Infirmary governed? How was it organized? It was in fact organized and governed by reference to what was called by a number of people “a club culture”. There were two or three or four people who moved around; they went to lunch together, they had meetings together. It was like a kind of swarm of a few; that was how the organization was managed, that was how decisions were made. It wasn't transparent, there wasn't any adequate system of breaking into that club culture. And the Medical Director, whom we have already mentioned as being somewhat autocratic, was also the Head of Surgery and he was also one of the “three wise men”. In that system, if you had a problem you took it to three wise men. Well, he was one of the guys you might be wanting to complain about. So you had, in governance terms, a system which was designed not to allow the very things that people were concerned about to surface. It's poor organization.

Then you had the Head of Department, who was there because it was “Buggins's turn”. On one occasion it became Mr Dhasmana and he hated being the head of that particular department. He hated it because he didn't like meetings, he didn't understand minutes and he really wanted somebody else to do it, but it was his turn. So you have got a system designed to fail to show leadership and fail to show proper transparent and workable governance, and the idea of “Buggins's turn” rather than the right person for the job is a very common feature in poor systems.

And then, of course, you had in governance terms something you are all familiar with, the need to occasionally do a bit of audit about what's going on. But the audit system was not formalized at all and when the meetings were called people either didn't go or, when they did, they argued about the data; not about what the data might say, but about the data. N = 1 was always where they started from and you can't really get much beyond that. They would argue: “well, my case is different because…”, and so you had pitched battles.

And the last thing about the governance was that when the Medical Director and the people at that level made reports, they were always anodyne, bland, “everything okay”. So there was no way whereby anybody up here could actually get a grip, and getting a grip asks the question: what about the Board? Could they find out? We had an occasion where the Chairman during the relevant time was sitting in this chair as a witness, and we brought up from among the 970,000 documents we had scanned into the system a document which was a letter to him warning him that someone was a little worried about the paediatric cardiac surgery and maybe people were being put at risk. I'll never forget, he blanched. He'd never seen that letter, because he was on holiday at the time and the letter was opened by the Chief Executive. Because it was about something that the Chief Executive thought maybe the Chairman ought not to be appraised of, he dealt with it himself, and perhaps did not deal with it in a way that it might have been dealt with. So if the Board – and this is as true now as it was then – is not engaged by being told what they need to be told and don't know what questions to ask because they are not sufficiently in tune with how a modern system works, then you have got another ingredient for failure. The Board doesn't know what to ask, it doesn't have a focus on safety and quality, it doesn't get told what might be embarrassing. When I asked the Chair of the Regional Health Authority, “Well, you know, didn't you have a track of the fact that there were some deaths taking place in this hospital?”, she said, “We measured the flow of patients, but it was throughput we were interested in, in terms of financial flows. We didn't know whether they came out dead or alive, it didn't really matter to us”. I swear that is what she said: “I did not know whether they came out dead or alive, it wasn't relevant to our task. Our task was to measure throughput, in terms of financial flows”. And so you have got no engagement with what is important. That also happened in Mid Staffordshire when we reported not very long ago, and there are many such examples where the Board is not told or is not aware of what is important.

The environment

This is the physical environment. This is about systems, not about bad people. And what was the system in Bristol to do this extraordinarily difficult surgery? There was a lift that went between the place where the operating theatre was and the intensive care unit. It was an adult intensive care unit. There wasn't any dedicated paediatric intensive care; there was a bed in the corner with a picture of a teddy bear, or something, to make it baby-friendly. But that lift wasn't a dedicated lift. If you got in, there was only just room for the gurney, the anaesthetist to hand ventilate the patient and, if she or he were slim, a nurse, and they'd go up. But if you didn't get to the button quickly enough you might go down somewhere else, and you might think there is a systems problem here about how to manage a system which is doing high tech surgery using Victorian facilities. There was no intensive care unit for paediatrics, as I have said. Furthermore, there was a split site. The children were admitted and had all their cardiology in a building on the hill, and it was 200 metres down the hill to trundle to where the operations took place, and occasionally the notes got lost. All sorts of stuff happened. It's nobody's fault. You all remember, some of you who have been to the Hammersmith in the days when it was redolent of the eighteenth century in every respect, and equally the London, where you have these elderly workhouses. Do you measure them in terms of whether they have cockroaches? Of course they have cockroaches, but how do you get rid of cockroaches? It was dirty, and this wasn't an environment, therefore, in which you would think that such surgery should be carried out. And the last example of the environment: parents were very worried about their children, obviously, and sometimes when the child had died they were grief-stricken, and where were they encouraged to be? There was a room, but it was variously described by parents as a broom-closet or a place where buckets and other stuff was stored. There was a chair in there and little else. Okay, it's a bad environment, but it's also bad thinking about the appropriate environment, and those things add up to systems failure, to the fact that you are not engaging with the needs of children and parents to the right degree.

The workforce, just as with my woman with the mop, are pretty important. The cardiologists serve the whole of the South West. It's about 160 miles from Bristol to Totnes, and they covered all of that. They had no trainees, because they were always on the move, and so what they had was a consultant-led service. So they were very rarely in the operating theatre, because they were out there flogging themselves doing other things. The nurses: it is very hard in the South West to recruit nurses, particularly in this area, because burn-out is quite high. When one mother asked whether she could show my colleagues and me her photographs while giving evidence, of course this was agreed. She brought these photographs of her daughter before her daughter had died – and that was part of the inquiry, which had to have a kind of cathartic effect for everybody. It is a form of letting go; people read their poems, or whatever – and we looked at the photographs. The nurses in the photographs, on the several days that the child was in, were wearing different-coloured uniforms. They were bank nurses, and if you have bank nurses you have got problems of continuity, you've got problems of experience, you've got problems of how dedicated they were, because they were in and out. This is another workforce issue of no stability in your nursing staff. And Mr Dhasmana in the theatre – those of you who are surgeons here will know this – was operating on something about the size of a walnut and he had three levels of magnification. Because the nurses were not dedicated to that theatre and often hadn't worked with him before, when he would put his hand out for something and they didn't know what he wanted, he'd get frustrated and so he'd try and find it for himself and his eyes had to adjust. He has got about 40 minutes of bypass time before the baby begins to be in some difficulty. If he is doing that five or six times and you work out how many half-a-minutes he has lost, it is 5–8% of his operating time just fiddling. It is those sorts of things which a good analyst would say shouldn't happen.

Teamwork

The surgeons and the cardiologists and the anaesthetists, as ever, didn't talk to each other and they were all at odds with each other because they were all unhappy with each other, and the nurses wondered: “How can we intervene? How can we do something to manage these warring fronts?”

Communication

Communication among the staff was appalling. There was a meeting called between the chap who was worried, Dr Bolsin, and the surgeons, and a mediator, the Senior Medical Director. They decided to meet at an Italian restaurant, and they had dinner for two-and-a-half hours and the point was to clear the air about the audit, about his fears about the children and whether they were being put at risk. What did they talk about for two-and-a-half-hours? Manchester United; Manchester United, because nobody could find the way to introduce the important topic of, “What are we going to do with those babies?” So communication between staff has broken down; that means the system is at risk; and communication with the parents was poor. Mr Dhasmana didn't like to talk to parents, he found it difficult. That's all right, just find someone else. One doctor trying to explain something to a parent pulled a piece of kitchen towel down and began to draw a heart, going through the kitchen towel as he did so, and you'd think “Blimey, why didn't they have a procedure…”, like they had at Birmingham; they had a video and they had a procedure worked out. So if you can't engage the parent adequately, the parent doesn't know what to expect and isn't informed.

Morale, therefore, was poor … I won't go into it in any great detail. When you have got poor morale, the system is at risk, and if you've got no insight … . Mr Wisheart went to work and it was his proud boast that his Volvo, his white Volvo (well known), was the first in the car park and the last to leave, and it never occurred to him that perhaps that wasn't how it ought to be, because he was flogging himself to death and he didn't have the insight to see that all of his judgement was at risk of being impaired because he was very tired.

I am going to conclude by asking, what do we learn from what I have just said? If we consider the past, although it is perhaps still also the present, what we are presented with is the classic approach of the GMC and, dare I say, the courts, which is a search for the cause – “What went wrong in Bristol? There must be a specific cause”, rather than a breakdown of systems. A young man was injected with vincristine. That was where the wrong substance went into his back and he was destined to die immediately, a 17-year-old boy in Nottingham. There were 40 departures from the procedure which had previously been ordained, because there had already been 13 examples of that taking place. The idea that there is a cause and therefore there is someone to blame is interesting but it misses the point. It mis-analyses or under-analyses the idea that there might be systemic failures, there might be human factors which need to be understood, because only if you understand them can you solve them, and therefore there is a failure to learn.

In Bristol no-one was prepared to talk to anyone else, to admit their failings, admit their near-misses, admit anything, because they couldn't talk about data; they couldn't talk about anything, they did not engage in some analysis which must be done, that is not to engage in blame. In the aeroplane industry, if you declare that you have done something within 48 hours you cannot be disciplined. You treasure errors and that allows you to learn and mitigate. So a systems approach, a human factors approach is, in my view, the only tenable and plausible approach which allows us when things go wrong to understand and therefore learn. Thank you. (Applause.)

Discussion

The President: Eddie Josse.

Dr Josse: I remember the Bristol inquiry well, sir, and of course but for the grace, you know, we could all fall into that sort of problem. I wanted to ask your view, however, about the blame situation, when an individual doctor is accused of a particular situation and is brought before a tribunal within the Health Service, be it for a Trust or a PCT. I have attended a number of these working through the Medical Defence Union acting as a friend of the doctor, and what has always struck me at these inquiries is that the bulk of the people involved in the inquiry on the panel are part of the Trust or part of the PCT and very rarely do you get a totally dispassionate external force coming in to listen, and to me that bedevils getting at what it is all about, and I just wanted your view about the this, because in Bristol you had an external group looking at the situation.

Sir Ian Kennedy: I will start back here a bit and say that when things go wrong (that's the title), there are two people or groups of people to be concerned with. One is the person who is harmed, harmed because something went wrong, not intentionally, or very rarely intentionally, and one is the person who caused that harm, caused that harm not intentionally, not with any guilty intent. As regards the person suffering the harm, the traditional approach that we have adopted in this country is that unless they are prepared to sue and take some legal action they are not going to get much by way of, “We understand; we are trying to do differently and, if you need some compensation, here it is”. They are not going to unless they bring a legal action, and a legal action requires them to prove a cause and show who did it, which in my view is completely the wrong way of doing things. That is why in Bristol I recommended that legal action against doctors for clinical negligence be abolished. I went to discuss that with the Lord Chancellor's Department before I recommended it and I received – and this is a quote which is not in the public domain but I will share it with you because it's true, because I said I was struck by the problem of blame and the blame culture, and the quote was: “Over here we believe in blame”. (Laughter.) Okay, there you go. So solving the problem of who is harmed is one part of the equation, and I don't think we do it at all well in this country. Then what do we do with the person who might have caused it? Well, first of all, we understand that he is part of a system, so to pick him or her out is already perhaps unfortunate, but there may be a circumstance in which, because something has gone wrong, one person says, “I am accountable for that system; I am the person who carries the can”, and that is right, and then the question is, what do you do about that? Do you say, “You're a bad doctor, you shouldn't ever work again as a doctor”; or do you say, “I as your employer think that you screwed up here and I'm going to take your job away”; or do you say, “You need some training here and this is what we would suggest for you”; or do you say, “We've all been there. Thank you. Move on”? There are a number of options and we are not at all sophisticated in the range of options we adopt, although in the last five to 10 years of approaches the GMC is beginning to try and understand that and localize and bring in the Sick Doctor Scheme. But those are the options. It is very rare in my view that you have someone who is malign, whether they be a nurse, a doctor, a midwife or whatever, and the question is what to do if they are taking responsibility, as, if they are in the leadership role, they should take responsibility, and it is very rare that you should say, “I'm going to boot them out”. It might be that you say, “Let's sit down and redesign this system so that it works properly”. So what you witnessed is something that is not designed to produce the right result, so you are right to be ticked off with it.

The President: John Garfield.

Mr Garfield: John Garfield, neurosurgeon, retired. We were left in Southampton because in 1965, as I think you know, we started from scratch, so we knew all the points you have talked about and we tried to follow them. Now, you have mentioned two words “throughput” and “money”.

Sir Ian Kennedy: Yes.

Mr Garfield: What do you feel about today's environment? Is it going to make what you say should happen, with which I totally agree, happen? Is it going to make it easier or more difficult for the people at the coalface?

Sir Ian Kennedy: If I may say so, it is probably the most significant question that every young doctor and nurse is currently asking him or herself. I was talking to the Chief Executive of the NHS about the announcement that there is going to be “X” amount of money. Next year the money is preserved and then it will be flat, so it won't be inflation-proof. The answer is that the leadership that the National Health Service is going to offer is one where money is not allowed to dominate the conversation but rather the values of the National Health Service – what do we believe in and what are we here for? – and then, secondly, the notion of quality, the quality of care. It has taken us 60 years actually to remember that quality is the central feature of the enterprise, but we got there with Ara Darzi. So values, purpose, quality, and then how can we produce that quality in the context of more constrained circumstances financially, and that is the right way to do it. Then lastly, in the achievement of the objectives of quality, the people who should lead us are the people who do the caring and the people who receive the caring, not the regime from Whitehall, and that is more or less accepted now. For example, I currently have a brief to look into Children's Services on behalf of the Chief Executive and I was in Tower Hamlets this morning looking at a thing called “Family/Nurse Partnerships”. Here they go to young, first-time mothers who are 15 or 16 and living in very chaotic circumstances, who would almost always fall through any kind of net and then themselves pose a problem to society, both financially and morally, and everything else, and bring into the world a child who has little or no hope or prospect of success. They are working at that and if they do it, there will be savings for society. It's not just about savings, it's about justice, it's about treating people properly. But the savings in terms of the Youth Offending Scheme and readmission to hospital and taking people into care – it costs £150,000 to take someone into care in some parts of this country, and this programme costs much less. So there is a real sense of dynamic thinking about how you can keep the values, keep the quality and deliver the service, and the money savings will follow that kind of radical thinking and move into the community. There are counter forces. If you create Foundation Trusts whose very survival depends upon attracting patients who are going to bring income, then you undermine the idea of caring for children, because they don't care about children. Children don't see doctors between vaccination and contraception for the most part, and so you have got some counter forces which you have got to work at. It is a fascinating architecture of policy challenge, for me anyway.

Dr Kaufman: Leon Kaufman, anaesthetist. I worked at Great Ormond Street in 1960. The surgeons there doing cardiac surgery were working on babies who were going to die anyway and the mortality was almost 100% and there was no Bristol-type inquiry. That is one thing.

The other thing is this: I was involved for the Crown in the case in Wales where they took out the wrong kidney. There were 20 stages where they could have picked this up. It all started with a houseman writing the wrong side and it went on and on and on. The sad thing is this chap could have survived, because they were taking blood samples every day and nobody thought to look at the results and the steroid levels were dropping hard, because the bad kidney was left behind and the adrenal had no blood supply and they took out the good kidney and they damaged the adrenal on the good side, and nobody in fact picked up that all he needed was some steroids.

Sir Ian Kennedy: Well, we all remember that case and the problem is, if you stand back like I do and say, “What's going on here?”, what is going on is that we keep having such cases. The chemical industry had Flixborough; the nuclear industry had Windscale; the aviation industry had PanAm landing on top of KLM in Tenerife; the oil and gas had Piper Alpha; they all had catastrophes, but they all learned from them. Some of you are old enough to remember Maria Caldwell, and then we had Victoria Climbie, and now we've had Baby P, and we'll have another one. What is it about the National Health Service and about what we do that doesn't allow us to learn from these? The vincristine was the fourteenth example of that, and that is one of the major challenges I am trying to address in the review of Children's Care because I am interested in, and am made to be interested in, what is called “safeguarding”. What is it about the National Health Service that stops it learning and putting into practice the lessons, so that we keep repeating this? Anaesthetists stand as being probably the most noble group, insofar as they began to analyse in the 1960s and onwards what was going wrong with patients and they began to introduce design approaches, systems. It wasn't a bad anaesthetist, it was that you could stick this tube into that tube and nothing would stop you, so sometimes you connected the wrong thing. Now you can't, because you design it out. The vincristine problem is still defying people designing it out, but anaesthetists reduced the mortality and morbidity level in their particular profession dramatically. Now, why haven't the rest of us begun to learn that? One thing that is amazing is that those of us who are the policy ones are all celebrating what is called the “surgical checklist”. Are you familiar with what is called the “surgical checklist”? It really only consists of “Who is the patient? Do we all agree this is Richard Bloggs? Do we all agree it is the left leg? I am Cindy, you're Joe”, everybody has got a name, and so on and so forth, but it's a start. It is doing what pilots do. Has anybody been in the cockpit of a big aeroplane? Pilots pull down something out of the ceiling, and they read things off to the co-pilot, who says “check”, the brakes, cigarette lighters, whatever it may be, it's all checked, and why do they do that? It's to eliminate discretion. It's to ensure that where you can standardize you do standardize, so that you cannot have a pilot who says, “I've been into Heathrow so many times I'm going to try it on two engines this time”, and the co-pilot says “Well, give it a go”. You can't do that because the black box will give you away and you have got all these people behind. The surgical checklist aims to eliminate discretion. You can't say “I've done this operation lots of times, I don't really care; I think it's the left leg”; you're not allowed to do that, and the fundamental politics of that, the fundamental culture of that, is to limit the sense of freedom and autonomy that we grant the profession, so it's resisted. There is room for judgement. The pilot does have to land the aeroplane on that river, and no-one else could do it, but he doesn't have to decide whether to put the flaps up and down, because everybody is supposed to do that, and that is where we need to go, that is part of that learning curve. That was a very long answer.

The President: May I ask you one final question? Are you going to sort out the “Westminster Village”?

Sir Ian Kennedy: Ah, that's another hat.

The President: I want a straight answer.

Sir Ian Kennedy: Well, in terms of systems and human factors … some of you may or may not know, I have been invited to chair the body that is to look into expenses, and probably pay as well. It is just a cultural challenge that had grown up, a sense of disappointment that one wasn't getting increases in pay since the late ’70s/early ’80s, Mrs Thatcher having said, “It doesn't look good”. So increasing use is made of what came to be called “allowances” – not expenses, but allowances – some of them are allowances, some of them are just straightforward expenses; you're not supposed to make money on expenses, it's supposed to be in and out; it was when I grew up anyway – and all these different allowance schemes developed. What one has to get back to is a cultural understanding. The big exam question I have, which may or may not solve your problem, and what I have got to consult on, including people like yourselves, is what amount of money from the public purse does a twenty-first century legislator need to do the job properly? That is the only question and I don't know the answer yet, but certainly just looking at expenses is somewhat proctoscopic in aspect. It is part of a larger picture, isn't it, and we have got to get that right.