The Government has published its response to the findings of the independent investigation into the death of Elizabeth Dixon including fitness to practise recommendations.
The Dixon investigation was commissioned in June 2017 by the then-Secretary of State for Health and Social Care, the Right Honourable Jeremy Hunt MP. The investigation, led by Dr Bill Kirkup, was tasked with investigating concerns about the death of 11-month-old Elizabeth Dixon in 2001, while under the care of a private nursing agency commissioned by the local health authority.
Elizabeth Dixon was a child with special health needs. She had been born prematurely at Frimley Park Hospital on 14 December 2000. Following treatment and care at Great Ormond Street Hospital and a children’s hospice, she was nursed at home under a care package. As a result of a failure to clear a tracheostomy tube, she asphyxiated and was pronounced dead at Frimley Park Hospital on 4 December 2001.
Recommendations from the report, addressed to the GMC and the NMC included:
- Professional regulatory and criminal justice systems should contain an inbuilt ‘stop’ mechanism to be activated when an investigation reveals evidence of systematic or organisational failures, and which will trigger an appropriate investigation into those wider systemic failures.
- Clinical error, openly disclosed, investigated and learned from, must not be subject to blame. Conversely, there should be zero tolerance of cover up, deception and fabrication in any health care setting, not least in the aftermath of error.
- Training in clinical error, reactions to error and responding with honesty, investigation and learning should become part of the core curriculum for clinicians. Although it is true that curricula are already crowded with essential technical and scientific knowledge, it cannot be the case that no room can be found for training in the third-leading cause of death in western health systems.
Summarised, GMC and NMC both recognise that just and learning cultures are critical in supporting people to raise concerns, and ensuring that those concerns are heard, responded to, addressed and learnt from. The government will continue to:
- work with GMC and NMC towards changing the wider system approach to patient safety
- evaluate the impact of existing guidance on behavioural change
- monitor the ways in which their guidance and standards are met through their quality assurance of education and training
GMC and NMC acknowledge that professional healthcare regulators have a part to play in tackling the blame culture that currently exists in the health sector. It is vital that regulators encourage environments that are inclusive and supportive, and promote a speaking up culture to eradicate the fear of blame and reprisal when things go wrong.
GMC and NMC have both made improvements to their fitness to practise processes as part of promoting an open and learning culture.
GMC has taken forward work to better understand human factors when things go wrong, and make sure contextual and system factors are appropriately considered during an investigation into a doctor’s practice. It will also be reviewing its guidance for decision-makers to include more information on how issues relating to systems may influence doctors’ performance so that these can be taken into account when making decisions about a doctor’s fitness to practise.
NMC has also improved the way in which it considers context in its fitness to practice processes by looking beyond the actions of an individual, and understanding the role of the culture, environment and system they were working in when something went wrong. It has provided training and support to colleagues to help them understand contextual factors more clearly, and ensure a consistent approach is taken where concerns are raised.
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