Older male man lies on a bed with his worried wife sitting with him, holding his hand.

Zero avoidable deaths – an aspiration, not a target

by Mel Ottewill

Mel Ottewill, National Investigator and Senior Investigation Science Educator, shares her thoughts on the Investigation Education Team's seminar on 7 June 2022 where Jeremy Hunt MP was the guest speaker. The seminar was chaired by Andrew Murphy-Pittock, Head of Investigation Education.

We were delighted to have Jeremy Hunt MP talk to our staff about his time as secretary of state, his passion for patient safety and his new book Zero.

Jeremy described arriving in office in 2012 when the Mid Staffs inquiry was in progress. He told us that at the time he knew very little about patient safety. He recalled being told that 10% of patients are harmed as a result of their care, and that was ‘just how it was’. He learnt that of all deaths, 4% are potentially avoidable – 150 patients per week unnecessarily dying! That’s equivalent to an airliner falling out of the sky every fortnight, and yet it wasn’t even spoken about. He described his overwhelming feeling that this was just wrong and that he had to do something about it.

After spending time listening to patients, families and staff he came to believe that the root of this harm arose from a deep-seated cultural problem that meant mistakes were not spoken about, were covered up and there was, in effect, a ‘complicity in falsehood’. Whilst nervous about cultural change, he felt convinced that no lasting improvement in patient safety would happen without a cultural shift.

This shift needed to be embraced by both families as well as staff. Jeremy recalled meeting bereaved families involved in the Morecombe Bay inquiry who were outraged that midwives involved in their baby’s care were still working. He was able to explain that while sacking those staff might have brought some emotional satisfaction for them, it wouldn’t provide any learning and ultimately could lead to more harm.

To support the much needed change in safety culture, Jeremy spoke about the benefits of a no-fault compensation system. He gave the example of Japan who introduced this in 2009 for serious cerebral palsy cases, alongside review and dissemination of learning from these events. As a result, incidents reduced by a third. New Zealand is another example of a no-fault compensation system. They spend half what England spends on litigation and compensation. So, far from being more expensive, it’s cheaper.

Jeremy talked powerfully about his belief in the aspiration of Zero. And the importance of this being exactly that – an aspiration not a target: "We have to stop in its tracks the idea that any preventable death is acceptable". If not, we ask how many is acceptable which is ethically wrong, and means we fall into the trap of setting our sights too low.

Jeremy’s challenge for HSSIB over the next five years was to discipline ourselves to consider that our job was done only when we could be certain our recommendations were implemented. Ultimately, for each and every investigation, we need to be able to evidence the reduction made in avoidable harm and death.

It is a significant challenge, for all sorts of reasons. But that shouldn’t stop us trying. This is reflected in Jeremy’s reference to the poet Antonio Machado: "Traveler, there is no path, The path is made by walking".

Find out more about our investigation education programme.

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