'Sorry' is still the hardest word

VIEWPOINT By Sir Liam Donaldson Chief Medical Officer for England

Things can go wrong even in the best hospitals

When something goes wrong in the NHS, staff can be reluctant to offer patients and relatives the apology they seek.

But in this week's Scrubbing Up health column, England's Chief Medical Officer Sir Liam Donaldson says the NHS needs to apologise more - and to mean it.

"She needs to move on", whispered one woman to the other. I was sitting behind them.

We were at a conference listening to a presentation from someone whose child had died as a result of a medical error.

"How can you move on from the death of your child?" I thought.

The risks of healthcare world-wide are higher than they should be and even the best-performing services inadvertently harm patients.

The problem is that the scale of harm in health care is much higher than might be expected.

A real apology has the power to transform

In developed countries, one in 10 patients in hospital suffers from a medical error.

A great deal of effort is now being put into reducing the risk of these errors. Less work and attention has been given to the aftermath of a tragedy.

Wall of resistance

Margaret Murphy's son, Kevin, was treated in Ireland in 1999.

He was a previously healthy young man who had a treatable illness which was not recognised or detected because of a series of errors, mix-ups and clinical blind-spots. He died aged 21.

A nurse burst into tears just after he died and told Margaret: "It should never have happened".

At first, the hospitals refused to even admit that mistakes had taken place, let alone explain the reasons behind them or apologise.

Margaret and her family met a wall of resistance in their simple quest for the truth. They did not want to litigate but were driven to it simply to find out why Kevin died.

During the five-year-long litigation process, they eventually found out exactly what had gone wrong in Kevin's treatment. Finally, they were offered an apology.

Sadly, this was done not in person but through legal representatives. Neither was there any indication of action that would be taken to prevent a recurrence.

All in the timing?

When the British bankers recently appeared before the House of Commons Treasury Select Committee they apologised. But afterwards, some commentators remarked: "Their apology did not seem sincere".

So what is a sincere apology? How is a patient to know whether the apology means anything to the person delivering it? Can the apology be judged on the way that it is spoken, the presence or absence of a look of compassion in the eyes? Is it all in the timing?

Sometimes apologies are used superficially, to deflect criticism. A statement may initially look like an apology - "We are very sorry that you are unhappy with the service you have received" - but on closer inspection there is no apology at all.

A true apology faces up to the reality that somebody has suffered due to the actions of others.

The NHS needs to learn to apologise more often - and it needs to learn to mean it

A real apology has the power to transform. The person receiving the apology knows that they have been listened to, and that there is true regret.

The person making the apology accepts their own or their hospital's part in the error, and feels empathy for the person who has suffered.

Apologies can be transformative for the whole National Health Service as well.

When an institution offers a genuine apology, the victim of the error is placed at the centre of its concerns. No institution can change or improve until first it recognises there is a problem.

Of course things can and do go wrong. That doesn't mean you aren't entitled to a sincere apology when it happens! Your comments

Apologies also need to be followed by action. Repeated surveys show that when a mistake is made, what patients want is not only a full apology but to know that action has been taken to prevent it from happening again, so that no other family can suffer in the same way.

Litigation is often a means to an end, and the only route that patients have when pitted against faceless organisations with no other route to redress.

Today, leading healthcare organisations around the world operate and promote policies of 'open disclosure'. This means being proactive when something goes wrong.

It means going to the patient or, after a death, the family and not just apologising but giving a full explanation of what really happened.

'Over my dead body'

There is no getting around it, making an apology is a tough thing for a doctor or nurse to do.

They may fear the patient's or relative's reaction. They may think it makes them more likely to be sued. They may simply not have the communication skills necessary to deal with such a highly charged, emotional encounter.

In recent discussions with NHS Trusts, staff showed a range of attitudes. Some accepted 'being open' as good practice, others were hostile. One respondent commented: "Over my dead body would I ever apologise".

There is great irony in that particular response since it is sometimes because of a patient's 'dead body' that the need for an apology is the greatest.

It can be hard for doctors and nurses to offer an apology

In Australia, a National Open Disclosure Programme has been running from some years.

When something serious has happened to a patient, a specially trained senior doctor accompanies the doctor who looked after the patient.

Open disclosure has been met with approval and relief by patients, families and clinicians. In the University of Michigan Hospitals, their full-disclosure programme halved the number of lawsuits and saved substantially on the litigation bill.

In even the best health systems, mistakes, although often preventable, will be made.

'Show you can learn'

The NHS must do everything it can to prevent those errors, but it also needs to be open when they do happen.

The National Patient Safety Agency is implementing a strategy of open disclosure, including apologising as and when necessary.

Margaret Murphy has moved on from the loss of her precious son Kevin killed by a series of medical mistakes. She is now a patient-champion for the World Health Organization's patient safety initiative.

She has moved on, but like many who have mourned the loss of a loved one to the errors of the increasingly complex healthcare system, she has not forgotten.

She calls for health services around the world to help her, and others, to forgive - by being honest and open when an error occurs.

For her, disclosure is not about apportioning or accepting blame - it is about being truly professional.

She told me that she did not want Kevin's death to be marked by a plaque on the ward or a tree planted in the hospital garden.

"Above all", she told me, "I want you [the health system] to honour Kevin's memory by showing that you can learn."

So an apology may be hard to deliver to a grieving mother but even that must never be an end in itself.

It must be the start of a journey of remembrance that will prevent the injury or save the life of a future patient.

Sixty years after its foundation, the NHS needs to learn to apologise more often. And it needs to learn to mean it.