Lessons From the Paterson Case: Treasure Mistakes and Learn From Them
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“There is another way,” Professor Sir Ian Kennedy told delegates at the Royal College of Surgeons of Edinburgh (RCSEd) Triennial conference. “We should not sue doctors when things go wrong...we should treasure mistakes and learn from them,” he stated bluntly.
He challenged the standard approach of using the ‘blame game’ to deal with rogue surgeons such as Ian Paterson, which he accused both the NHS and lawyers of pursing.
“I am a reformed lawyer – the law is the problem not the solution,” he said.
But, the question he posed at the start of his presentation addressing the lessons learnt from Paterson asked why we continue to see these familiar cases – and implicit to this, why have we not learnt the lessons.
He pointed to institutional failings at all levels where trusts choose to invoke HR procedures to shroud the process in secrecy, and which involves reintegration of the person into the team – the team that had been so bullied and intimidated.
Professor Kennedy asked again: “What are the lessons – and there are many? The training of leaders – it is the job of leaders to train leaders.” But, his subsequent criticism of the need for whistle blowing “admits people don’t trust the system and admits failure because you don’t have an empowered workforce”.
It was clear that Professor Kennedy’s great personal sadness was that the ultimate cost of Paterson was borne by the hundreds of women he harmed, whose lives will never be the same again.
The blame game continued as Professor Kennedy’s final slide illustrated the face of now disgraced Dr Bawa Garba: “She is an example of blame, no one was concerned that she was looking after six wards.”
But, in his final statement in answer to a question on how to challenge bullying behaviour that causes patient harm and distress to colleagues, Professor Kennedy said: “Standing back and seeing how systems work is the critical thing.”
Read also Abi Rimmer's article on Professor Sir Ian Kennedy's keynote speech on The BMJ website.
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