How families see the ‘system’ during healthcare investigations

My thoughts on how families can see the ‘system’ during healthcare investigations – Kate Jury, Managing Partner

‘Systems’ thinking has been a vital tool in reducing blame and supporting cultures of openness and accountability, but there must still be a balance achieved between the system and its relationship to the individual, particularly where families are concerned.

Referring to ‘no blame’, ‘system’ or ‘thematic’ approaches to understanding what has happened to patients or their loved ones – outlined within  Patient Safety Incident Response Framework (PSIRF) – was going to sit uncomfortably with some families and their needs for truth and accountability in that moment. The risks of compound harm occurring from poorly handled restoration or investigation processes are high.

To many families, ‘systems’ represent something that staff can hide behind, and which restrict open dialogue around harm. In our experience, families want to see reflection and personal accountability from staff to feel able to move on and all too often this is characterised as ‘blame’. With this in mind, sometimes, ‘systems thinking’ prevents families from getting this closure and, in this sense, families can feel excluded from the ‘just culture’ and restorative approaches which are now being promoted.

How families involved in an investigation can see the ‘system’

We have worked with families who, as many as eight years down the line, are still waiting for an apology or a real acknowledgement of their pain and suffering because of the various hoops and injunctions created by ‘the system’.

It is ‘the system’ they feel they need to fight. Many families enter adversarial processes, taking legal action, or referring directly to professional bodies, because they feel that they have not been provided with truth and accountability because of ‘system learning’. Not every error or harm can be assumed to be because of an imperfect system, and families need more in the way of accountability.

Understanding what families want to see and understanding what resolution would look like to them is key. This might not be a ‘day in court’ or disciplinary action. Sometimes it could just be the removal of the ‘system’ barrier, to invite rather than close a dialogue between staff and families.

Introducing this ‘parity’ within the relationship is vital and centres on healing, responsibility, and more open dialogue between families and staff.

If you would like to discuss how your organisation can work toward introducing this ‘parity’ – contact us via the ‘Get in touch’ option on our site.