I wish to start by congratulating my hon. Friend Dr Johnson on securing this really important debate on patient safety. All patients have a right to expect care that is compassionate, effective and safe. The courageous testimonies of individuals such as Julie Bailey, who exposed the scandalous failings at Mid Staffordshire NHS Foundation Trust, and Sara Ryan, who campaigned fearlessly following the death of her son, Connor Sparrowhawk, while in the so-called care of Southern Health, show that safer care starts with listening to patients and their families.
It is important that we recognise that there are many victims when care fails—the families and the loved ones, of course, but also the healthcare professionals who carry the burden of their mistakes. The great majority of NHS patients receive effective and successful care. However, according to international studies, levels of healthcare harm range from 1% for the most “negligent” adverse events, to 8% to 9% for preventable adverse events. We are clear that any level of harm over 0% is unacceptable, and we believe that the route to a safer NHS is through transparency, learning and action. What is most frustrating is when harm persists, despite our having the knowledge and wherewithal to prevent it. There are approximately nine “never events” in the NHS every week—avoidable harms such as wrong-site surgery or foreign objects left after an operation.
Thirty years ago, the aviation industry stood at a similar crossroads. Since then, there has been a massive reduction in fatal accidents every decade, despite a huge increase in the number of passengers. According to the Civil Aviation Authority, there is an average of one fatality for every 287 million passengers carried by UK operators. Compare that with the 150 avoidable deaths every week across the NHS. That rate would potentially equate to the loss of 52 airliners per year.
How has the airline industry transformed its safety record so successfully? The key has been a “just culture” that recognises honest human error, but continues to hold people to account for criminal acts or wilful negligence. Creating a safe space that protects the evidence provided by pilots and air traffic controllers when there is an investigation is a cornerstone of the approach. It helps to create a culture in which people can be open about their errors and a system of learning from one’s mistakes, rather than blaming individuals.