Swansea Bay Independent Maternity and Neonatal Review
Click here
On February 4th 2020 the report of the independent inquiry into the practice of breast surgeon Ian Paterson was released.
In it was a damning catalogue of errors, and pages upon pages of detail about the story of a healthcare system which proved itself dysfunctional at almost every level when it came to keeping patients safe. Who, working in health, will ever forget the increasingly amplified alarm bells sounding at Mid Staffordshire NHS Foundation Trust, culminating in the Robert Francis QC Report of the Public Inquiry in 2013. From individuals acting with intent (Harold Shipman) to the impact of faulty medications on public health or the failure of an IT system to recall patients. Indeed, there are probably many, multi-population serious incidents (MPSIs) which the public never even hear about.
What is a MPSI and are we in fact dealing with more of these? An MPSI is, as the name suggests, a single issue, erroneous factor or harm which affects multiple groups or populations. We might initially assume that an MPSI involves just the cohort of patients who are directly affected by the event, but there is a world of impact beyond this. We must also consider the serious harm in terms of impact upon families and loved ones as well as the deeply negative impact upon staff, other service users and other services who may be operationally affected by the events, who are thrown into a scenario where they are providing continuity.
It is crucial when considering the impact of MPSIs that you are able to draw concentric circles around the central (or index) event, to determine not only the immediate harm but also the proxies to the harm. In reality, for each person harmed by an MPSI, there are likely to be around 20 more affected for each; and that is a deeply conservative estimate.
This is why, when a MPSI is discovered, a different procedural approach is required. This is different to that of a standard Incident Management Policy and also distinct to Emergency Preparedness Plans. Healthcare providers are becoming increasingly adept at dealing with large-scale catastrophic events: take for example, the Grenfell Tower response or the looming presence of coronavirus. There are some key facilitating mechanisms which might be employed in a scenario like this, such as the Civil Contingencies Act (CCA) but what happens when incidents are iatrogenic – caused by the very healthcare organisations who are meant to heal and protect?
There are special considerations both in the immediate management of MPSIs and also in relation to the investigation of the circumstances surrounding the event and sharing the resultant learning. In our review of provider Incident Management Polices which are publicly available we found very few which might begin to address the handling of multi-population serious Incidents as a specific category. Additional guidance for organisations to enable them to respond in a decisive and controlled way, would be useful. Considerations when a potential MPSI has been alerted might include:
All of the above items in turn might take at least a week each to develop under normal circumstances, but, in the event of a MPSI you might only have five days in totality, to rapidly mobilise a plan, and in most circumstances this is less. Many organisations find out at this point that their existing policy and procedural documents are woefully inadequate to support the eventuality of a MPSI.
MPSIs are perhaps more common than we think. Many organisations in the last ten years have had issues with screening and recall programmes, or IT failures which have resulted in the wrong letters being sent. Then there are the infinitely more high-profile MPSIs; Paterson, Mid-Staffordshire, Bristol Heart, and Harold Shipman. Of course, no one can really prepare for events of this magnitude (particularly where individuals are acting with intent), but, it is likely that most of these organisations in retrospect would change things about their approaches in the aftermath of the scenario. Particularly, that they didn’t make things worse by inadvertently looking like they were trying to cover-up events because of their sheer disorganisation in the face of such operational chaos. Or indeed, those organisations who did try to defend the indefensible, managing successfully in their response to turn an inflamed situation into an eventual firestorm.
Once organisations have been able to deal with the immediate crisis, to provide care to those harmed or to fully understand the extent of the issue, the next step is a full investigation.
It is interesting to note that, with increasing public scrutiny on healthcare services, a ‘public inquiry’ is often the first chant from MP benches. There are, however, some academics who feel that the increasing reliance upon the public inquiry (which seeks to elicit a ‘single version of the truth’ as is the want of the High Court Judge) is not the ideal response. As Nicholas Timmins (Ely and After 2018) indicates, such NHS inquiries, whilst there is always merit to the investigation, can have weak follow-up mechanisms and Timmins questions whether these are the best pathways to help the NHS to learn, given so many of these incidents are so multi-factorial. Given the (likely) multi-million-pound bill to the tax-payer, this is money which is then not spent on patient care.
At an imprecise number, there have been around 120 public inquiries into health-related incidents since the Ely psychiatric hospital scandal in 1967. Many key strategic policy changes have come about because of public inquiries, Duty of Candour, DBS checks, and other regulation have all introduced seismic and lasting positive change (Timmins, Ely and After 2018). However, as Timmins also argues, one of the primary purposes of inquiries is that affected families gain answers and have some form of cathexis; this isn’t always the case in the current system .
Arguably, it is independent investigators who should ensure that their scope is expansive enough to make recommendations at the national level so that these might determine future policy decisions; this simply does not always need to be done via the route of the public inquiry. Often, investigations will focus upon providing family resolution as well as organisational reforms rather than pinpointing exactly what regulatory and governmental bodies need to change to effect real and sustainable change nationally. This should be a specific focus going forward; how the scope of the independent investigation has the architecture to cover all bases through recommendations. At the moment, the scope of many independent investigations does not allow for recommendations at the national level or at other agencies not immediately covered by health such as prisons or the police.
Large scale investigations should, importantly, promote pan-organisational learning so that the whole public sector can learn equally from MPSIs. Better knowledge capturing will help to promote a much earlier identification of issues and can support other processes such as mortality governance. Coroners should also be involved as their role could be central in ensuring that organisations respond effectively to prevent a future occurrence of harm.
When we think about MPSI’s we might be restricted to thinking within the form of an organisation, i.e. something goes wrong in a trust or G.P which affects multiple people.
However, at what point do we consider the same incidents in multiple healthcare providers an MPSI? If we took the same approach to extracting learning at the national policy level to, for example, domestic homicides, then might we see a greater impact nationally on incidents with the same or similar causal factors?
Equally, should we make more effort to ensure that we support a healthcare culture which is much more conducive to learning from MPSIs? Might we agree that in the age of high-turnover healthcare and technological advancement that we might see the rise of more incidents which affect more patients? Is this simply a symptom of advancing healthcare? In that case, should we better mobilise our governance systems to a) identify MPSIs at an earlier stage and b) have more decisive interventions to promote better, more impactful resolution. The answer is not always a public inquiry. Nor, is the solution the encroaching threat of the American class action – rarely does the involvement of lawyers actually help the NHS to learn and improve.
What seems clear in the world today is that when things go wrong, they can seem to go wrong in a way which impacts multiple populations; healthcare organisations are not ready for this tide of inevitability. As in so many cases, the answer to this stealth threat must always be better governance, governance, governance and all of the constituent parts therein.
Kate Jury is Partner in Governance and Assurance at Niche.
Contact Kate.Jury@nicheconsult.co.uk
Wakefield Council, Wakefield CCG, and a range of local provider organisations are working together.
Read more
Ben Himsworth explores the strange history of the lobotomy
Read more
We support our clients to understand and improve all aspects of mortality governance from reporting through to practice improvement...
Read more
©2025 Niche Health & Social Care Consulting.
Company Registered number 08133492
Design and build by Future
