The Community Pharmacy Patient Safety Group made the comments in its contributions submitted to Professor Sir Norman Williams’ review of gross negligence manslaughter in healthcare, published last month (June 11).
The report followed the decision of the High Court to rule in favour of the General Medical Council (GMC) appeal that Dr Hadiza Bawa-Garba be removed from the medical register. Dr Bawa-Garba was found guilty of manslaughter by gross negligence in 2015, in relation to the death of a six-year-old boy at Leicester Royal Infirmary in 2011.
The pharmacy group – one of 22 organisations to provide written evidence to the review – “welcomed” the report to ensure the public and professionals are “better informed” about gross negligence manslaughter.
However, it “would be extremely disappointed if an unintended consequence of this tragic case was the regression to a blame culture in any part of the health and care system, or a move towards a more risk-averse form of healthcare”, the group told C+D.
After seeing a “shift in culture” across the pharmacy sector in recent years, to more “open and honest reporting” and accompanying improvements in patient care, “a pursuance of recriminatory processes now would set back the patient safety agenda at least 10 years”, it warned in its contribution to the review.
No “safe haven” for pharmacy professionals
The group said it was “concerned” by the GMC’s decision to strike Dr Bawa-Garba off the medical register and claimed her “reflections about the incident and her admission of culpability were used against her” during the criminal trial.
“Some pharmacy team members” raised concerns about reporting following similar incidents where police investigating pharmacy professionals “demanded” incident report forms, “regardless of whether they were relevant to the particular incident under investigation”, the group said.
“There is currently no ‘safe haven’ for pharmacy professionals to provide a full and frank account of an incident to support root cause analysis and learning alone,” it stressed.
“Our current experience is that investigations, certainly those undertaken by the police within community pharmacy, are heavily focused on the failure of an individual, which can make the responsible pharmacist particularly vulnerable,” the group added.
It also referenced cases of pharmacy professionals being investigated for manslaughter, which “has an obvious and detrimental effect on a healthcare professional’s mental health and wellbeing”.
Systems or individuals at fault?
“Contributory factors” should be taken into account during police proceedings, the group recommended. “Investigations and guidance should include a focus on whether the death of a patient is caused by systems failure or individual failure.”
In November 2017, the group published it priorities for 2018 – including its Report, Learn Share, Act, Review principle – which committed to increase reporting and improve learning from errors in pharmacies.
In its contribution to the review, it stressed that a “‘high’ reporting rate should not be interpreted to mean a pharmacy is ‘unsafe’ and may actually indicate a culture of greater openness and a commitment to patient safety improvement”.
Pharmacy professionals must be confident that their “professionalism, openness and honesty will not be used against them by the criminal courts or their professional regulator”, the group stressed.
Read the patient safety group’s contribution to the Williams review here.
C+D spoke to leading healthcare lawyers about the Williams review and what impact the Dr Bawa-Garba case will have on community pharmacy. Read the analysis here.