How the Infected Blood Inquiry could lead to a cultural shift that puts patient safety first - Victoria Morris

I believe it will make a difference. It feels somehow different from the long line of similar reports, partly because of the report itself, and partly because of the timing, set against the backdrop of the Post Office Inquiry and of course Mr Bates vs The Post Office, which has sparked public interest – and outrage - in a way no public inquiry has achieved previously.

Likewise, the Thirlwall Inquiry, currently underway into the events at the Countess of Chester hospital, has further cast NHS culture into the spotlight.

It is distinct, pointing (as so many other reports have done) to the need to refocus on safety, involving cultural change, but in a way which is contained, easy to understand and easy to monitor. It holds the potential for genuine and transformative change.

One of the most immediate impacts has been the Government's acceptance of the recommendation on compensation. While this step is essential for addressing the impact on many patients whose lives were catastrophically affected, it is just the beginning.

The report calls for proper recognition and remembrance of the victims and apologies that go beyond token gestures, ensuring that the acknowledgment of past mistakes is genuine and impactful.

The report calls for a fundamental shift in the NHS’s approach to safety. Safety must not just be a core principle, but ‘the first’ principle. This will mean reforming the current regulatory system, which can be fragmented and confusing, into a more streamlined and coherent approach.

Effective data handling is another critical area. The inquiry calls for a unified approach to data collection and analysis to identify and address potential threats and measure outcomes. By improving data management, the NHS can better detect risks and implement preventive measures, thereby fostering a safer healthcare environment.

The report goes below the surface to cultural defensiveness within both the NHS and the Government, identifying it as a symptom of ‘groupthink’ - a failure to listen to concerns or challenge the accepted view, of doing what has always been done, resulting in patients’ concerns being repeatedly dismissed. The Inquiry calls for a cultural transformation that promotes openness, accountability and the willingness to embrace challenge.

To address the issues identified in the Infected Blood Inquiry, the report recommends the introduction of a statutory duty of candour for public servants. This measure is intended to promote transparency and ensure that similar failures are not repeated. By holding public servants accountable for their actions and decisions, the duty of candour seeks to prevent recurrence. This duty should also extend to non-medically qualified hospital managers. Clinicians already owe this duty.

At the Labour party conference on September 24, the Prime Minister announced the acceptance of Hillsborough Law - a landmark piece of legislation that will force public bodies to cooperate with investigations into major disasters, with failure to comply potentially resulting in criminal sanctions. The law is set to take effect by April 2025, marking a significant step towards accountability and transparency in the aftermath of public tragedy.

The Inquiry provides a clear blueprint for reform. Its recommendations extend beyond mere procedural changes, calling for a deep-seated cultural shift towards greater openness putting safety above reputation within the NHS and the broader public sector.

This will require every NHS organisation to understand their true position on safety and their response to concerns – whether they are welcomed, or sidelined and suppressed. Those affected by national tragedies like Hillsborough, the Post Office scandal and Grenfell all speak with one voice in wanting more than just recognition, an apology and compensation, but crucially some accountability for what happened to them.

Sir Brian has made clear his determination to have his recommendations implemented or a clear explanation if they are not. He noted that the suffering caused by these issues is profound, and the responses from various authorities have often compounded this harm. He plans to follow up on the Government’s actions in 12 months and has recommended that a parliamentary affairs Select Committee oversees implementation and holds the government to account.

None of this is easy, but I am optimistic that Sir Brian’s tenacity, combined with the anticipated findings of Thirlwall and ‘the Mr Bates effect’ will combine to produce a cultural shift, enhancing patient safety with the hope of re-earning public trust.

Victoria Morris is a partner at Weightmans and one of the lawyers who represented the Blood Services during the Infected Blood Inquiry.