The Secretary of State for Health and Social Care announced on 6 February 2018 that he was asking Professor Sir Norman Williams to conduct a rapid policy review into the issues pertaining to gross negligence manslaughter in healthcare.
Working with stakeholders, the Review considered:
- how to ensure healthcare professionals are adequately informed about:
- where and how the line is drawn between gross negligence manslaughter (GNM) and negligence;
- what processes are gone through before initiating a prosecution for GNM;
- how the vital role of reflective learning, openness and transparency is protected where the healthcare professional believes that a mistake has been made to ensure that lessons are learned and mistakes not covered up;
The Review also explored the lessons that need to be learned by the General Medical Council (GMC) and other healthcare professionals’ regulators in relation to how they deal with professionals following a criminal process for gross negligence manslaughter.
The Community Pharmacy Patient Safety Group submitted evidence as part of the Review.
In summary, we stated that:
- We would be extremely disappointed if an unintended consequence of the tragic death of Jack Adcock and the following case against Dr Bawa-Garba was the regression to a blame culture in any part of the health and care system, or moves towards a more risk-averse form of healthcare
- An appropriate balance must be struck – currently the GPhC, employers, patients and professionals expect and potentially require (e.g. as part of GPhC standards) that pharmacy professionals are open and honest, and reflect when things go wrong to help organisations understand the factors that have led to an incident so that lessons can be learned/shared, yet these reflections and analysis can then be demanded as part of a criminal investigation and used against the individual involved
- It often feels as though the ultimate goal of regulatory action is to improve public safety and patient care, yet the ultimate goal of a criminal investigation is usually to punish an individual – which makes the responsible pharmacist particularly vulnerable when things go wrong
- There is vast inconsistency in the approach taken by police forces in handling incidents involving healthcare professionals and it is not clear who advises them on proportionality and reasonable expectations. Professionals have a relatively clearer understanding of what to expect from their regulator (due to decision-making guidance being published) but criminal processes are much less clear so we would welcome further guidance on this.
- Public understanding of regulatory action and the application of learning should be improved – a lack of criminal conviction does not equate to a lack of action/learning and a conviction does not automatically lead to improved safety.
- We were particularly concerned by the approach taken by the GMC in this case, especially in the context that the Department of Health recently consulted on proposals to merge several of the healthcare regulators.