AS CHAIRMAN of the Healthcare Commission, regulation is Sir Ian Kennedy’s business. But six years after the watershed inquiry he conducted into the avoidable deaths of up to 150 young children at Bristol Royal Infirmary over a decade, vital lessons on how to improve patient safety across the NHS have still not been learnt, he says.

After a career as a lawyer, professor and writer on medical law and ethics, Sir Ian’s report into the high mortality rates of babies undergoing heart surgery at the hospital – described as written in anger – pulled no punches. On its release in 2001 he made a series of urgent recommendations to reduce the risk to patients in maternity and general care.

Watchdogs such as the Healthcare Commission and the National Patient Safety Agency (NPSA) were charged with a duty to promote safety across the NHS.

But despite this, there is still a crucial lack of data on medical and surgical mistakes that are estimated to cause thousands of deaths or injuries every year. A similar tragedy could be happening again in the NHS today and we would not know it, he says.

“Bristol was an opportunity to say something about how children were looked after, but also offer more general lessons about safety. In the foreword to the report I said I could not say that this sort of thing couldn’t be happening again, somewhere else, and it remains the case.”

He is an amiable interviewee, bristling with anecdotes and asides, but there is a serious message and he insists that it is not scaremongering: “Our statutory duty is to encourage improvement in the provision of healthcare. We do that by drawing attention to what is good, so that it can be shared, but also to what needs to be looked into because it is not yet meeting the right standards.”

While paediatric cardiac surgery in Britain is now among the best in the world, “there are other areas of healthcare where we haven’t had that sustained focus, that spotlight, and one can’t be sure that all the factors required for safe care are actually there”. The problem is particularly acute in maternity services, where the highest birth rate for 26 years is now coinciding with widespread reconfiguration of services and a lack of staff. Such factors, as well as poor management, are warning signs for potential tragedies, he says.

But healthcare regulation relies mainly on hospitals and NHS trusts self-reporting their successes and failures, with follow-up checks as necessary. Yet in terms of medical errors, the perceived threat of blame and the legal consequences leads doctors and managers, worryingly, to “cover them up”. Sir Ian is scathing about his former profession and sees the culture of medical litigation as a “major barrier” to general patient safety.

The NHS should, like other major risk-laden industries, “treasure” errors as vital lessons that can be learnt from. But “there is an absence of political will to make this a high priority and collect the data”.

He adds: “If it was the intention of the present Government to signal what the priorities were in healthcare, why wasn’t there a target on near-misses or accidents reported, which would have focused attention on the problem?”

But the NHS doesn’t want any more targets. So the key now is for it to improve the core standards, on which the commission currently assesses trusts. “If we as a regulatory body can promote improvements in terms of safety then I will feel that I’ve achieved a great deal. That’s why it is our first priority.”

David Rose is Health Correspondent of The Times

Born: September 14, 1941, in Tipton, West Midlands

Career: Law degree at University College London, 1963; barrister, Inner Temple 1974; Professor of Medical Law and Ethics, King’s College London 1986; president, Centre of Medical Law and Ethics, 1992; chairman of public inquiry into paediatric cardiac surgery at Bristol, 1998-2001; appointed KBE and made chair of the Healthcare Commission in 2002.

What he says: “It is quite easy for children to fall out of the attention of those who make decisions about priorities, allocation of resources and training.”

Little-known fact: Keeps wicket for the University College London staff cricket XI and supports West Bromwich Albion

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